Sholpan Zhangelova

Background and Objective. Epistaxis is a frequent bleeding manifestation in patients receiving antithrombotic therapy, and its management falls between otolaryngology and cardiology guidance. We aimed to translate the evidence into an operational framework for joint decisions. Methods. PubMed/MEDLINE, Scopus, Embase, and the Cochrane Library were searched (January 2015 through August 2026), current ESC, ACC/AHA, EHRA, AAO-HNS, and SFORL guidance were analyzed, and national clinical protocols of different countries were screened; 67 sources were included. Results. Direct oral anticoagulants were consistently associated with fewer clinically relevant epistaxis events than warfarin, and minor epistaxis led to permanent anticoagulant discontinuation more often than minor bleeding at other sites. No guideline defines epistaxis severity, and guidance diverges on protected dual antiplatelet therapy, bleeding-risk assessment, and the sequence of local hemostasis and drug interruption. We propose a three-tier severity classification (minor, clinically relevant non-major, major) informed by ISTH and BARC definitions, a pragmatic thrombotic risk stratification, and an algorithm with agent-specific decisions. Conclusions. In minor and most clinically relevant non-major episodes, antithrombotic therapy can usually be continued while local hemostasis is achieved; interruption, de-escalation, or reversal should be individualized and reserved for uncontrolled or major bleeding. Effective local hemostasis can help avoid unnecessary interruption of antithrombotic therapy, and otolaryngologists should be part of multidisciplinary teams managing such bleeding.

Background: Patients with coronary artery disease (CAD) receiving dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remain at risk of early adverse outcomes, including in-hospital mortality. Simple risk stratification based on routinely available variables may help identify higher-risk patients, but a limited number of outcome events constrains robust prediction-model development and validation. Aim: This exploratory study aimed to derive a preliminary, interpretable clinical score based on routinely available variables for risk stratification of all-cause in-hospital mortality in CAD patients receiving DAPT after PCI. In the clopidogrel-dominant practice setting of the participating centers, the score was conceived as a hypothesis-generating risk-enrichment framework rather than a validated treatment-selection tool or a surrogate measure of platelet reactivity. Methods: We analyzed a retrospective cohort of 1600 adults with CAD admitted between 2022 and 2024; 36 in-hospital deaths occurred. Twenty demographic, clinical, laboratory, and instrumental variables were evaluated. The primary outcome was all-cause in-hospital mortality during the index hospitalization. For exploratory score derivation, the dataset was randomly divided into a derivation subset (75%; n = 1200) and a hold-out assessment subset (25%; n = 400). Predictors were explored using univariable and multivariable logistic regression with stepwise selection. Continuous variables were categorized using Weight of Evidence binning, and an integer point score was derived. Performance was summarized using ROC analysis, AUC, sensitivity, specificity, and accuracy. Given the small number of deaths and the data-driven modelling workflow, all performance estimates were considered preliminary rather than definitive internal validation. Results: The exploratory six-variable score included age ≥ 57 years, estimated glomerular filtration rate < 45 mL/min/1.73 m², body mass index ≥ 25 kg/m², troponin I ≥ 100, prior myocardial infarction, and current smoking. In the derivation subset, each additional point was associated with higher odds of mortality (OR 1.39; 95% CI 1.29–1.51; p < 0.001), and the AUC was 0.654. A Youden-index threshold of approximately 6 points yielded sensitivity of 0.41, specificity of 0.80, and accuracy of 0.72. In the hold-out assessment subset, sensitivity was 0.53, specificity was 0.70, accuracy was 0.70, and AUC was 0.61. These estimates indicate modest discrimination and should be interpreted cautiously because only 36 outcome events were available. Conclusions: This exploratory clinical score showed modest discrimination for all-cause in-hospital mortality and should be regarded as a preliminary, hypothesis-generating risk-stratification approach. It is not sufficiently validated for routine prognostic classification, platelet-reactivity triage, or antiplatelet treatment selection. Model redevelopment using event-efficient methods, resampling-based internal validation, and subsequent external validation are required before clinical implementation.

Background: Patients with coronary artery disease (CAD) receiving dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remain at risk of early ad-verse outcomes, including in-hospital mortality. Simple risk stratification based on rou-tinely available variables may help identify higher-risk patients, but a limited number of outcome events constrains robust prediction-model development and validation. Aim: This exploratory study aimed to derive a preliminary, interpretable clinical score based on routinely available variables for risk stratification of all-cause in-hospital mor-tality in CAD patients receiving DAPT after PCI. In the clopidogrel-dominant practice set-ting of the participating centers, the score was conceived as a hypothesis-generating risk-enrichment framework rather than a validated treatment-selection tool or a surrogate measure of platelet reactivity. Methods: We analyzed a retrospective cohort of 1,600 adults with CAD admitted between 2022 and 2024; 36 in-hospital deaths occurred. Twenty demographic, clinical, laboratory, and instrumental variables were evaluated. The primary outcome was all-cause in-hospital mortality during the index hospitalization. For exploratory score derivation, the dataset was randomly divided into a derivation subset (75%; n = 1,200) and a hold-out assessment subset (25%; n = 400). Predictors were explored using univariable and multi-variable logistic regression with stepwise selection. Continuous variables were catego-rized using Weight of Evidence binning, and an integer point score was derived. Perfor-mance was summarized using ROC analysis, AUC, sensitivity, specificity, and accuracy. Given the small number of deaths and the data-driven modelling workflow, all perfor-mance estimates were considered preliminary rather than definitive internal validation. Results: The exploratory six-variable score included age ≥57 years, estimated glomerular filtration rate <45 mL/min/1.73 m², body mass index ≥25 kg/m², troponin I ≥100, prior myocardial infarction, and current smoking. In the derivation subset, each additional point was associated with higher odds of mortality (OR 1.39; 95% CI 1.29-1.51; p < 0.001), and the AUC was 0.654. A Youden-index threshold of approximately 6 points yielded sensitivity of 0.41, specificity of 0.80, and accuracy of 0.72. In the hold-out assessment subset, sensitivity was 0.53, specificity was 0.70, accuracy was 0.70, and AUC was 0.61. These estimates indicate modest discrimination and should be interpreted cautiously be-cause only 36 outcome events were available. Conclusions: This exploratory clinical score showed modest discrimination for all-cause in-hospital mortality and should be regarded as a preliminary, hypothesis-generating risk-stratification approach. It is not sufficiently validated for routine prognostic classifi-cation, platelet-reactivity triage, or antiplatelet treatment selection. Model redevelopment using event-efficient methods, resampling-based internal validation, and subsequent ex-ternal validation are required before clinical implementation.

Актуальность: Проанализирован опыт применения четырехкомпонентной модели педагогического дизайна (4C/ID) на кафедре оториноларингологии в учебном процессе резидентуры по специальности оториноларингология. Цель: Оценить эффективность внедрения методики 4C/ID в образовательный процесс резидентов-оториноларингологов. Материалы и методы: В исследовании приняли участие 37 резидентов-оториноларингологов. Для оценки эффективности методики 4C/ID использовался метод онлайн-анкетирования по специально разработанной анкете. Категориальные переменные анализировали путем вычисления доли (в процентах) каждого значения. При нормальном распределении данных использовали среднее арифметическое (М) и стандартное отклонение (SD) с применением Microsoft Excel 2013. Количественная переменная оценивалась по десятибалльной шкале до и после внедрения методики. Достоверность различий оценивалась с помощью непараметрического критерия Вилкоксона. Различия считались статистически значимыми при p < 0,05. Результаты: После внедрения методики 4C/ID значительно выросла субъективная оценка интереса к обучению (91,9%), качества знаний (97,3%), взаимодействия с преподавателем (89,2%) и уровня сформированных навыков. Средняя оценка практических навыков возросла с 6,05 ± 2,11 до 9,14 ± 1,25. Различия статистически значимы (p = 0,0000016, критерий Вилкоксона). Выводы: Модель 4C/ID является эффективным инструментом развития практических навыков резидентов-оториноларингологов и рекомендуется к внедрению в систему последипломного медицинского образования. Background: This study analyzes the experience of implementing the Four-Component Instructional Design model (4C/ID) in the educational process of the Department of Otorhinolaryngology within the residency program. Aim: To assess the effectiveness of the 4C/ID model in the educational process of otorhinolaryngology residents. Materials and Methods: The study involved 37 otorhinolaryngology residents. An online questionnaire was used to assess effectiveness. Categorical variables were analyzed as percentages. For normally distributed data, mean (M) and standard deviation (SD) were calculated using Microsoft Excel 2013. Quantitative variables were assessed on a ten-point scale before and after implementation. Statistical significance was evaluated using the non-parametric Wilcoxon test (p < 0.05). Results: Following implementation, subjective assessment of interest in learning (91.9%), perceived knowledge quality (97.3%), interaction with the instructor (89.2%), and practical skill development increased significantly. Mean practical skills score rose from 6.05 ± 2.11 to 9.14 ± 1.25 (p = 0.0000016, Wilcoxon test). Conclusion: The 4C/ID model is an effective tool for developing practical skills in otorhinolaryngology residents and is recommended for implementation in postgraduate medical education. Өзектілігі: Оториноларингология мамандығы бойынша резидентураның оқу процесінде оториноларингология кафедрасында педагогикалық дизайнның төрт компонентті моделін (4C/ID) қолдану тәжірибесі талданды. Мақсаты: Резидент-оториноларингологтардың білім беру процесінде 4C/ID әдістемесін енгізудің тиімділігін бағалау. Материал және әдістер: Зерттеуге 37 резидент-оториноларинголог қатысты. Педагогикалық дизайнның (4C/ID) төрт компонентті моделі әдістемесінің тиімділігін бағалау үшін арнайы сауалнама бойынша on-line сауалнама жүргізу әдісі пайдаланылды. Айырмашылықтардың маңыздылығы Вилкоксонның параметрлік емес критерийі арқылы бағаланды (p < 0,05). Нәтижелері: 4C/ID әдістемесін енгізгеннен кейін оқытуға қызығушылық (91,9%), білім сапасы (97,3%), оқытушымен өзара іс-қимыл (89,2%) және практикалық дағдылардың қалыптасу деңгейі едәуір өсті. Практикалық дағдылардың орташа бағасы 6,05 ± 2,11-ден 9,14 ± 1,25-ке дейін өсті (p = 0,0000016). Қорытынды: 4C/ID моделі оториноларингология резиденттерінің практикалық дағдыларын дамытудың тиімді құралы болып...

Background: Optimal platelet inhibition is essential for minimizing both thrombotic and hemorrhagic complications in patients with coronary artery disease (CAD). Although high on-treatment platelet reactivity (HPR) has been consistently associated with adverse clinical outcomes, the relationship between platelet reactivity—measured as P2Y12 reaction units (PRU)—and cardiovascular mortality remains incompletely characterized. In particular, potential non-linear associations have not been adequately explored. Objective: We aimed to investigate the association between PRU and cardiovascular mortality in patients with CAD, with a specific focus on identifying potential non-linear relationships. Methods: We conducted a retrospective observational cohort study including 1000 patients with angiographically confirmed CAD treated at a tertiary cardiology center in Almaty, Kazakhstan, between 2024 and 2025. Platelet reactivity was assessed using the VerifyNow P2Y12 assay. Multivariable logistic regression models were used to identify independent predictors of cardiovascular mortality. To assess potential non-linear associations between PRU and mortality, restricted cubic spline regression was applied with predefined knot placement. Model performance was evaluated in terms of discrimination (C-statistic) and calibration (Hosmer-Lemeshow goodness-of-fit test). Results: In conventional linear regression models, PRU was not independently associated with cardiovascular mortality (odds ratio [OR] ~1.00; p > 0.05). However, spline-based analyses demonstrated a statistically significant non-linear (U-shaped) relationship between PRU and mortality risk (p for non-linearity = X). Both low and high PRU values were associated with increased mortality, whereas intermediate PRU levels corresponded to the lowest observed risk. Additional independent predictors of mortality included advanced age, diabetes mellitus, and elevated inflammatory markers. Conclusions: Our findings reveal a significant non-linear association between platelet reactivity and cardiovascular mortality in patients with CAD. Both insufficient and excessive platelet inhibition appear to confer increased risk, suggesting that optimal PRU targets may lie within an intermediate therapeutic range. These results support a paradigm shift toward more individualized antiplatelet therapy strategies guided by platelet function testing.

Background: High residual platelet reactivity (HRPR) and persistent dyslipidemia remain important unmet needs in cardiovascular risk management, particularly in patients undergoing coronary revascularization. Despite intensive lipid-lowering and antiplatelet therapy, a substantial proportion of patients fail to reach recommended low-density lipoprotein cholesterol (LDL-C) targets or exhibit inadequate platelet inhibition. Inclisiran, a PCSK9-targeting small interfering RNA, represents an emerging approach for long-term LDL-C reduction. Methods: A narrative review of the literature published between 2009 and 2025 was performed using PubMed, Scopus, Web of Science, and MEDLINE. Studies evaluating the addition of inclisiran to standard lipid-lowering therapy in patients with dyslipidemia and HRPR, assessed using the VerifyNow assay, were included. Illustrative clinical cases from Kazakhstan were analyzed to demonstrate real-world changes in LDL-C levels and platelet reactivity following insufficient response to conventional treatment. The review had a descriptive design. Results: Available evidence indicates that a significant proportion of high- and very-high-risk patients do not achieve LDL-C targets or are unable to tolerate high-intensity statin therapy. Inclisiran consistently induces sustained reductions in LDL-C and circulating PCSK9 levels. Emerging data suggest a potential indirect modulation of platelet reactivity associated with intensive lipid lowering. In patients at extreme cardiovascular risk—including those after coronary artery bypass grafting (CABG) and with long-standing multivessel coronary artery disease—inclisiran therapy was associated with marked LDL-C reduction and a trend toward normalization of platelet reactivity. Conclusions: Assessment of platelet function using the VerifyNow assay may improve identification of residual thrombotic risk in patients with advanced atherosclerotic disease. Inclisiran appears to be a promising adjunctive therapy for dyslipidemic patients with persistently elevated cardiovascular risk and HRPR despite standard treatment. Further prospective studies are warranted to clarify the relationship between intensive LDL-C lowering, platelet reactivity, and clinical outcomes, and to optimize integrated lipid-lowering and antiplatelet strategies.

Background: Coronary artery bypass grafting (CABG) remains a standard revascularization strategy for patients with advanced coronary artery disease (CAD). However, a considerable proportion of patients experience recurrent ischemia requiring repeat revascularization. Residual platelet reactivity (RPR) and dyslipidemia are recognized as key factors contributing to graft failure and disease progression. Methods: This observational study was conducted at a tertiary cardiology center in Kazakhstan. A total of 195 post-CABG patients who underwent repeat coronary angiography between 2023 and 2024 recruitment period for recurrent ischemic symptoms within 6–36 months after surgery were included. Clinical characteristics, comorbidities, lipid profiles, and antiplatelet response were analyzed. RPR was measured using the VerifyNow P2Y12 assay when available. Dyslipidemia was defined according to the 2019 and 2021 European guidelines. Results: Elevated RPR was identified in 45% of patients (n = 90) despite dual antiplatelet therapy (p < 0.01). Poor lipid control was frequent among those who underwent repeat percutaneous coronary intervention (PCI), particularly elevated levels of low-density lipoprotein cholesterol (LDL-C) and total cholesterol (p < 0.05). Both elevated RPR and dyslipidemia were independently associated with native coronary disease progression and graft failure (RPR: OR = 2.8; 95% CI 1.4–5.6; p = 0.003; dyslipidemia: OR = 2.2; 95% CI 1.1–4.3; p = 0.02). The use of ezetimibe was independently associated with a significantly lower risk of repeat stenting (OR = 0.12; 95% CI 0.02–0.75; p = 0.023). Smokers were younger, had lower blood pressure, and less frequently presented with diabetes or chronic kidney disease, demonstrating a pattern consistent with the “smoker’s paradox.” Conclusions: Residual platelet reactivity and dyslipidemia are common and clinically relevant predictors of repeat revascularization after CABG. Optimization of antiplatelet and lipid-lowering therapy should be prioritized in secondary prevention for this high-risk population. These findings are particularly important in Kazakhstan, where post-CABG management strategies warrant further improvement.

Introduction. Polymorbidity in the form of uncontrolled arterial hypertension, heart failure, severe out-of-hospital polisegmental pneumonia complicated by pleurisy and respiratory failure significantly affects the tactics of myocardial infarction management in polypragmatic conditions and worsen prognosis. Additional difficulties in myocardial infarction management are: Dressler syndrome, recurrent course of infarction and ventricular fibrillation, repeated interventions (coronarography and stenting), contrast induced nephropathy on the background of chronic heart failure with low ejection fraction and pulmonary hypertension. Material and methods. Analysis of the medical record data of patient B, 58 years old. Results and discussion: This case highlights the challenges faced by physicians in the management of patients with myocardial infarction on polymorbid background, requiring simultaneous intensive treatment of myocardial infarction and combined diseases, which increases the risk of circulatory instability in conditions of forced polypragmasy. Conclusion:This case demonstrates the need for active identification of patients with CHD at the outpatient stage and interdisciplinary approach including general practitioners, internists, cardiologists, cardiac surgeons, pulmonologists, intensive care specialists and nephrologists. Введение. Полиморбидность в виде неконтролируемой артериальной гипертензии, сердечной недостаточности, тяжелой внебольничной полисегментарной пневмонией, осложненной плевритом и дыхательной недостаточностью существенно влияет на тактику ведения инфаркта миокарда в условиях полипрагмазии и ухудшают прогноз. Дополнительные сложности в управлении инфарктом миокарда представляют: синдром Дресслера, рецидивирующее течение инфаркта и фибрилляции желудочков, повторные вмешательства (коронарографии и стентирования), контраст индуцированная нефропатия на фоне хронической сердечной недостаточности с низкой фракцией выброса и легочной гипертензии. Материал и методы. Анализ данных медицинской карты пациента В, 58 лет. Результаты и обсуждение: Данный случай подчеркивает вызовы, с которыми сталкиваются врачи при ведении пациентов с инфарктом миокарда на полиморбидном фоне, требующих одновременного интенсивного лечения инфаркта миокарда и сочетанных заболеваний, что повышает риск нестабильности кровообращения в условиях вынужденной полипрагмазии. Вывод: Этот случай демонстрирует необходимость активного выявления пациентов с ИБС на амбулаторном этапе и междисциплинарного подхода, включающего врачей общей практики, терапевтов, кардиологов, кардиохирургов, пульмонологов, реаниматологов и нефрологов. Кіріспе. Бақыланбайтын артериялық гипертензия, жүрек жеткіліксіздігі, плевритпен және тыныс алу жеткіліксіздігімен асқынған ауруханадан тыс полисегментарлық пневмония түріндегі полиморбидтілік полипрагмазия жағдайларында миокард инфарктісін жүргізу тактикасына елеулі әсер етеді және болжамды нашарлатады. Миокард инфарктін басқарудағы қосымша қиындықтар: Дресслер синдромы, инфаркттің және қарыншалардың фибрилляциясының қайталанатын ағымы, қайталама араласулар (коронарография және стенттеу), төмен шығарынды фракциясы мен өкпе гипертензиясы бар созылмалы жүрек функциясының жеткіліксіздігі фонындағы индукцияланған нефропатияның контрастысы. Материал және әдістер. В, 58 жастағы пациенттің медициналық картасының деректерін талдау. Нәтижелері және талқылауы: Бұл жағдай мәжбүрлі полипрагмазия жағдайларында қан айналымының тұрақсыздығы қаупін арттыратын миокард инфарктін және аралас ауруларды бір мезгілде қарқынды емдеуді талап ететін полиморбидті фонда миокард инфарктімен ауыратын пациенттерді емдеу кезінде дәрігерлер кездесетін сын-қатерлерді баса көрсетеді. Қорытынды: Бұл жағдай жалпы практика дәрігерлерін, терапевтерді, кардиологтарды, кардиохирургтарды,...

Background: Coronary artery bypass grafting (CABG) is a standard treatment for ad-vanced coronary artery disease (CAD). Despite its effectiveness, many patients devel-op recurrent ischemia requiring repeat revascularization. Residual platelet reactivity (RPR) and dyslipidemia are considered important contributors to graft failure and dis-ease progression. This study investigated the association of RPR and dyslipidemia with repeat revascularization in post-CABG patients. Methods: A observational cohort study was performed at a tertiary cardiology center in Kazakhstan. A total of 200 patients with prior CABG who underwent repeat coro-nary angiography between 2023 and 2024 for recurrent ischemic symptoms were in-cluded. Clinical data, comorbidities, lipid profiles, and antiplatelet response were ana-lyzed. RPR was measured with the VerifyNow P2Y12 assay where available. Dyslipidemia was defined according to current European guidelines, 2019/2021. Results: Elevated RPR was found in 45% (n = 90) of patients despite dual antiplatelet therapy. Poor lipid control, especially increased low-density lipoprotein cholesterol (LDL-C) and total cholesterol was common among patients undergoing repeat percu-taneous coronary intervention (PCI). Both RPR and dyslipidemia were independently associated with native coronary disease progression and graft failure. Conclusions: RPR and dyslipidemia are frequent and clinically relevant predictors of repeat revascularization after CABG. Optimizing antiplatelet and lipid-lowering ther-apy should be a priority in secondary prevention for this high-risk group. These results are particularly important in the Central Asian setting, where post-CABG management strategies require further improvement.

Aim. To study real-world data on managing patients with coronary artery disease (CAD) and multifocal atherosclerosis (MFA) for 12 months by outpatient cardiologists.Material and methods. KAMMA is a real-world registry organized by the Eurasian Association of Therapists. The main branch included men and women over 18 years of age with confirmed atherosclerosis in two or more arterial systems and one or more risk factors for atherosclerosis. The start date for patient recruitment was February 1, 2022 and the end date was November 27, 2022. The design included 3 following visits: 1 — baseline, 2 — after 6 months, 3 — after 12 months. Twentyeight research centers were located in 7 federal districts of the Russian Federation, as well as in the Republics of Kazakhstan, Uzbekistan and Belarus.Results. A patient population (n=2905) was formed, all of whom had verified CAD. The mean age was 66,0 [59,0; 72,0] years (men — 60,3%). Low-density lipoprotein cholesterol decreased by 20,4% over 12 months, while non-high-density lipoprotein cholesterol — by 12,7%. Over 12 months, lipid-lowering therapy did not undergo significant changes. Statin monotherapy was maintained in 83%, of which only 53,7% of patients received high-dose therapy. Combined statin+ezetimibe therapy was used in 12,4%, while statin+ezetimibe+PCSK9 inhibitor — in 4,6%. During the 1-year follow-up, antithrombotic therapy was not enhanced. Low prescription rate of combination therapy with antiplatelet agents (15,7%) and low-dose rivaroxaban and acetylsalicylic acid (7,9%) remained. By the follow-up end, a high incidence of major adverse cardiovascular events (8,8%) was registered in patients included in the KAMMA registry.Conclusion. Despite the fact that patients with MFA have a very high cardiovascular risk, routine management of these patients is characterized by high clinical inertia. During the 1-year follow-up, lipid-lowering and antithrombotic therapy was not properly strengthened, due to which the target levels of key lipid profile parameters were not achieved and a high rate of major adverse cardiovascular events was observed in patients included in the registry.