Variability of Measurement and Feasibility of Assessing Changes in Brachiocepahlic Atherosclerotic Plaque After Acute Coronary Syndrome.

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) mm2. 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) mm2, 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.

New Possibilities to Reduce the Residual Risk in Patients with Ischemic Heart Disease.

Despite a significant progress of the recent decades, incidence of cardiovascular complications in patients with manifest, stable ischemic heart disease (IHD) is still high. Furthermore, this patient group is heterogenous; individuals with a higher risk of cardiovascular complications can be isolated from this group based on the presence of comorbidities and acute IHD on the background of the therapy. Such patients require a more aggressive treatment to influence major components of the increased risk. Even after administration of an optimum therapy, the risk for complications in such patients remains high (residual risk). The article discusses the lipid, inflammatory, and thrombotic components of residual risk in IHD patients and possibilities of their control with drugs with a special focus on possibilities of pharmaceutical correction of the risk thrombotic component in IHD patients with diabetes mellitus.

[Revascularization in Stable Ischemic Heart Disease: Whether to Change the Approach?]

Current international guidelines on stable ischemic heart disease (IHD) state that coronary revascularization is indicated in cases of: limiting ischemic symptoms while on optimal medical therapy (OMT); high risk coronary anatomy; high risk stress test result. At the same time, many results supporting these conclusions were obtained in relatively old studies, conducted when the approaches to medical therapy and revascularization techniques differed greatly from contemporary practice. Many of the conclusions have been based on data from observational studies and subanalyses of randomized clinical trials, therefore methodologically are not sufficiently reliable. Moreover, the results of more modern trials do not coincide with the older. This situation has generated contradictory opinions on the indications for coronary revascularization in patients with IHD in the cardiology community. This review contains analysis of the evidence base of current revascularization guidelines, data on components of OMT, and discussion of the need for large-scale randomized clinical trial comparing effectiveness of OMT and OMT+revascularization in patients with stable IHD.

[CURRENT VIEWS OF DIAGNOSTICS AND STRATEGY OF THE TREATMENT OF STABLE ISCHEMIC HEART DISEASE].

Ischemic heart disease (IHD) is a leading cause of mortality worldwide and stable IHD is one of its most important clinical forms. Recent decades brought new data on algorithms of diagnostics, pharmacotherapy and myocardium revascularization in patients with stable IHD. They were summarised in American (2012) and European (2013) recommendations on the management of this condition. The present paper is designed to discuss these algorithms with reference to the currently available evidence, results of the last studies and international guidelines.

[Prediction of Subclinical Carotid Atherosclerosis With Parameters of Negative for Ischemia Exercise Testing].

AIM: to elucidate relationship between parameters of negative ischemic stress test and subclinical atherosclerosis of carotid arteries. MATERIAL AND METHODS: Electrocardiographic stress test on treadmill and ultrasound study of carotid arteries (CA) were carried out in 204 patients (100 women and 104 men, mean age 54.16±8.07 years without verified ischemic heart disease and with ≥ 1 traditional factors of cardiovascular risk). Measurements of intima media thickness (IMT) in three extracranial CA segments and identification of atherosclerotic plaques (AP) were used for detection of subclinical atherosclerosis. CA total atherosclerotic plaque area (TAPA) was calculated when appropriate. RESULTS: Multifactorial regression analysis revealed the following predictors of increased IMT and TAPA: physical working capacity, increment and reserve of heart rate (HR), HR restoration, and increment of systolic arterial pressure (SAP). Presence of atherosclerotic plaque was associated with SAP rise > 42% during exercise test and slow HR restoration (≤42 bpm at 2-nd minute of recovery period). CONCLUSION: Analysis of nonelectrocardiographic parameters of negative relative to ischemia induction exercise test allows predicting severity of atherosclerotic changes in CA. The information obtained can supplement assessment of traditional factors of cardiovascular risk.

[Revascularization or conservative strategy in patients with stable coronary heart disease: a contemporary view].

Choice between revascularization and conservative strategy in patients with stable coronary heart disease (CHD) is an important clinical problem, especially when the need for revascularization is not urged by severe ischemic symptoms. Revascularization aimed to improve prognosis is most justified in patients having high risk, based both on results of coronary angiography and functional tests. In the opinion of many experts, the high-risk features at stress-test is a key to identify patients in whom revascularization is most required among persons with high-risk coronary anatomy, as well as to select candidates for invasive treatment among patients with more favorable variants of coronary lesions. The advantage of revascularization over conservative treatment was demonstrated primarily in relation to coronary bypass surgery; however, the prospect of replacing surgery by an interventional treatment for prognostic reasons is extremely attractive. Although comparison of prognostic efficiency of percutaneous coronary intervention (PCI) and coronary bypass surgery (CABG) for some categories of patients with stable ischemic heart disease has yielded encouraging results, improved survival when using the PCI in direct comparison with optimal medical therapy was not convincingly confirmed to date. Implementation of PCI to improve prognosis in stable ischemic heart disease is still limited by a rather narrow range of indications and the relief of symptoms of ischemia remains its main purpose.

[Individual coronary heart disease risk prediction as part of primary prevention].

Correction of traditional risk factors (RF) at the population level resulted in considerable progress in prevention of coronary heart disease (CHD) in many countries. At the same time existing approaches to individual prediction of cardiovascular diseases based on the analysis of traditional RF and global risk scoring are in some cases ineffective. This problem most notably relates to a large group of persons with low calculated risk (young patients, persons without multiple RF, women) which accounts for the greatest in absolute numbers quantity of primary cardiovascular events. Attempts of improvement of individual CHD prediction deal with 1) discovering of new RF and their introduction in global scoring models, 2) cardiovascular imaging modalities which facilitate diagnosis of subclinical atherosclerosis, first of all an ultrasonic study of carotids and multi-detector computed tomography of coronary arteries. This review considers the prognostic value of most important standard global risk scoring models, the added value of new RF and role of data received from atherosclerosis imaging.

[Prediction of left ventricular remodeling after acute myocardial infarction].

Prediction of adverse left ventricular remodeling after acute myocardial infarction (AMI) may have important clinical implications. In this study, we evaluated the incidence of unfavorable changes of left ventricular volumes and ejection fraction after AMI. The ability of several cardiac markers, electrocardiographic and echocardiographic (including tissue Doppler) variables to predict adverse remodeling was demonstrated. The prognostic algorithm based on the investigated variables may help improve the treatment of patients after AMI.

[Advanced age as a risk factor for heart failure after acute myocardial infarction].

Heart failure (HF) is one of the most unfavorable consequences of the acute myocardial infarction (AMI), resulting in increased hospitalization level and mortality. The patients of advanced age constitute the major part among patients with HF due to AMI. In 123 patients a number of variables of the acute phase were investigated as potential predictors of developing HF within 12 months after AMI and the role of age was assessed. The relation of HF, echocardiographic variables measured 12 months after infarction and age was also studied. On completion a one-year follow-up, 54 patients (44%) developed HF, mainly of 2nd NYHA class. The age of the patients was the only independent predictor of HF among the variables of the acute phase (OR = 1.06 under 95% CI (1.01-1.12). The age over 65 years demonstrated 78% sensitivity and specificity in predicting development of HF. Among parameters estimated at the end of 12-months follow-up, age (OR = 0.934 under 95% CI (0.889-0.983) and echocardiographic wall motion score index (WMSI) (OR = 0.031 under 95% CI (0.003-0.333) independently influenced the presence of HF The factor of age had decisive importance for HF development in group of the patients with medium infarct size. At WMSI range 1.6-1.89, 11 of 20 patients younger than 65 had no HF, whereas 8 of 9 patients older than 65 developed HF (p < 0.05). Thus, age is a major independent predictor of development of HF within the first year after AMI. The patients of the senior age group 65+) have a high risk of HF with medium infarct size, which does not result in HF in patients of younger age.