[ISCHEMIA - the Largest Ever R andomized Study in Stable Coronary Artery Disease. Baseline Characteristics of Enrolled Patients in One Russian Site].

Indications for coronary revascularization in patients with stable coronary heart disease (CHD), presented in the current international guidelines are largely based on the clinical trials conducted sometimes more than 30 years ago. ISCHEMIA is the major multicenter international randomized trial intended to answer the question about the optimal treatment strategy in stable coronary artery disease at the present time. PURPOSE: To analyze the most important baseline characteristics of patients enrolled in the ISCHEMIA study in one Russian site. METHODS: The principal inclusion criteria are a positive stress test (in our center, exercise stress echocardiography) of at least moderate risk and obstructive coronary heart disease confirmed by coronary computed tomography angiography (CCTA). Main exclusion criteria are a significant stenosis of the left main coronary artery by CCTA, clinical progression/destabilization of the ischemic heart disease, angina of IV CCS class, left ventricular ejection fraction (EF) 80% - beta blockers, >80% - ACE inhibitors/ARBs. They are at well controlled resting heart rate (.

[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.

[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.

[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 (100women and 104 men, mean age 54.16+/-8.07 years without verified ischemic heart disease and with more or equal 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 ( less or equal 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.