Viktoriya E. Gumerova

BACKGROUND: In the context of a steadily aging population and a progressive increase in the incidence of cardiovascular diseases, coronary heart disease with coronary artery calcification is a critical issue in modern cardiology. The progressive calcification of the vascular bed with age not only serves as an independent predictor of cardiovascular complications but also poses significant challenges in selecting the optimal strategy for endovascular revascularization in patients in older age groups. AIM: To conduct a retrospective analysis of the effectiveness of treatment in patients with coronary heart disease and coronary artery calcification in elderly and senile age. METHODS: We analyzed clinical data and quality-of-life indicators in two groups of patients: group 1 (main) with endovascular intervention and group 2 (comparison) with drug therapy alone. The level of calcified vascular lesions was determined using coronary angiography and a method for selecting treatment tactics (Patent RU2831567C1). RESULTS: The groups were comparable by functional class of angina: functional class III, 97 (83.6%) and 114 (83.2%) patients in groups 1 and 2, respectively; functional class IV, 19 (16.4%) and 23 (16.8%) patients; by sex: men, 82 (70.7%) and 96 (70.1%) patients; women, 34 (29.3%) and 41 (29.9%) patients; by age: 72 ± 8.9 and 73 ± 8.1 years. Both groups were comparable in terms of the main selection criteria but differed in terms of the presence of obesity: the body mass index was 27.9 ± 1.8 and 29.1 ± 1.6 kg/m², respectively, in groups 1 and 2. The groups were comparable by the presence of concomitant diseases: arterial hypertension, 61 (52.6%) and 95 (69.3%) patients; diabetes mellitus, 41 (35.3%) and 84 (61.3%) patients; smoking, 44 (37.9%) and 77 (56.2%) patients in groups 1 and 2, respectively. In the long-term follow-up, the mortality rate of patients in both groups did not differ significantly. In the main group, there was a decrease in the angina class (φemp = 2.329; p = 0.05). The probability of adverse cardiovascular complications and the risk of restenosis had a small but statistically significant intergroup difference (φemp = 2.049 and φemp = 2.088, respectively; p = 0.05). CONCLUSION: The degree of coronary calcification in the conservative therapy group was associated with a significantly higher incidence of diabetes, hypertension, and smoking in these patients compared with the main group. Despite the lack of impact on overall survival, endovascular treatment allows for significant improvement in physical activity and psychoemotional status, which is critically important for prolonging active longevity and improving the quality of life of patients of elderly and senile age.

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.

Objective. Comparison of vascular stiffness and a presence of traditional risk factors of cardiovascular diseases (CVD) in middle-aged men with arterial hypertension (HTN) and type 2 diabetes mellitus (DM). Design and methods. We examined 180 middle-aged men. All patients were divided into 3 groups of 60 people: group 1 (control) — healthy normotensive patients, group 2 (HTN) — patients with hypertension and group 3 (HTN and DM) — with hypertension and diabetes. All subjects underwent 24hours ABPM with assessment of routine and average daily parameters of blood pressure (BP), indicators of central and peripheral vascular stiffness. Results. The average daily values of systolic blood pressure (SBP) and pulse blood pressure (PBP) differ significantly between all pairs of groups, with the highest PBP in group 2. Subjects in groups 2 (HTN) and 3 (HTN + DM) had significantly higher average diastolic blood pressure (DBP). The average indicators of BP variability are worse in group 3 (HTN + DM), both for DBP and SBP. The following differences in central parameters of vascular stiffness and central pressure in the aorta were identified: DBP in the aorta (DBP ao) and mean blood pressure in the aorta (MAP ao) are higher in group 2. The augmentation index in the aorta (Alx ao) is higher in group 3, PAD amplification (PPA) and reflected wave propagation time (RWTT) are higher in group 2. Conclusions. In middle-aged men with HTN central SBP and PBP, aortic and peripheral stiffness are greater than in the control group. Central stiffness is more severe in HTN patients. Peripheral indicators of vascular stiffness are more increased in patients with HTN and DM.

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: Arterial hypertension is widespread in the population, leads to the development of arteriosclerosis and increase of arterial stiffness, and is the main non-lipid risk factor of atherosclerosis development. Multiple studies have shown that increase of arterial stiffness is an independent risk factor for the development of cardiovascular events. However, the influence of traditional cardiovascular risk factors on arterial stiffness in arterial hypertension and atherosclerotic process of different degrees of severity has not been sufficiently studied. AIM: To assess the influence of traditional risk factors on the parameters of arterial stiffness in patients with arterial hypertension (AH) and atherosclerotic process of varying degrees of severity. MATERIALS AND METHODS: 133 subjects with AH have been divided into 3 groups depending on the severity of the atherosclerotic process. The control group included 33 individuals without known cardiovascular diseases. All the participants have undergone a standard clinical and laboratory examination, 24hr blood pressure monitoring with assessment of arterial stiffness (AS) parameters. The influence of risk factors on AS parameters has been analyzed for all the participants and separately by groups. RESULTS: In the AH patients, an increase in the arterial stiffness index (ASI) is associated with an older age and an increase in systolic blood pressure (SBP); an increase in the augmentation index (AIx75) is associated with age; SBP in higher in women. Pulse wave velocity in the aorta (PWVao) is most associated with age, smoking, and family history in patients with hypertension and subclinical atherosclerosis. An increase in AIx75 is associated with an older age and is higher in women, while ASI has a positive relationship with age and SBP. In patients with hypertension and coronary artery disease, there is a positive correlation between male body mass index and PWVao. The increase in ASI in this group is associated with female gender, SBP and age. In individuals without hypertension and signs of atherosclerosis with a family history of CVD, PWVao values are higher than in similar individuals without a family history of CVD. CONCLUSIONS: In the group of all the participants, female gender, smoking, an older age, SBP, and body mass index are associated with increased AS parameters. The association between risk factors and parameters of arterial stiffness has peculiarities in patients with hypertension with varying degrees of severity of the atherosclerotic process.

Aim. Assessment the arteries' stiffness parameters and subendocardial viability ratio in hypertensive patients with various degrees of severity of the atherosclerotic process manifestation.Material and methods. 133 hypertensive patients were divided into 3 groups, similar in age and sex, depending on the severity of the atherosclerotic process: hypertensive patients without atherosclerosis (n=42; 53.3±7.6 years); patients with hypertension and subclinical atherosclerosis (SА) (n=52; 56.5±8.0 years); patients with hypertension and coronary artery disease (CAD) (n=39; 57.4±6.8years) and control group which consisted of individuals without cardiovascular diseases (n=33; 54.6±8.4 years). All participants underwent 24-hour blood pressure monitoring with assessment of arterial stiffness parameters and subendocardial viability ratio (SERV).Results. Subjects from all groups with hypertension have significantly higher mean systolic blood pressure (SBP) (131.1±11.9, 127.8±14.8, 128.6±15.3 respectively; pConclusions. In hypertensive patients with SA, a decrease in subendocardial perfusion is associated with an increase in pulse wave velocity in aorta. Moreover, such a decrease in perfusion approaches to the values of patients suffering from coronary artery disease, which indicates significant changes in the small vessels of the heart that form the coronary reserve.