[Cardiovascular effects of omega-3 polyunsaturated fatty acids: position of omega-3 polyunsaturated fatty acids in Russian and international guidelines. Council of Experts].

This Expert Council focuses on the meta-analysis of studies on the risk of atrial fibrillation (AF) in patients taking omega-3 polyunsaturated fatty acids (PUFA) and of data on the omega-3 PUFA treatment in patients with cardiovascular and kidney diseases.The major statements of the Expert Council: the meta-analysis of AF risk in patients taking omega-3 PUFA showed an increased risk of this arrhythmia. However, it should be taken into account that the risk of complications was low, and there was no significant increase in the risk of AF when omega-3 PUFA was used at a dose of ≤1 g and a standard dose of the only omega-3 PUFA drug registered in the Russian Federation, considering all AF episodes in the ASCEND study.At the present time, according to Russian and international clinical guidelines, the use of omega-3 PUFA can be considered in the following cases: • for patients with chronic heart failure (CHF) with reduced left ventricular ejection fraction as a supplement to the basic therapy (2B class of recommendations according to the 2020 Russian Society of Cardiology guidelines (RSC) and the 2022 AHA / ACC / HFSA guidelines); • for patients with hypertriglyceridemia (>1.5 mmol/l) as a part of combination therapy (IIb class of recommendations and B level of evidence according to the 2021 European guidelines on cardiovascular disease prevention, etc.); • for adult patients with stage 3-4 chronic kidney disease (CKD), long-chain omega-3 PUFA 2 g/day is recommended for reducing the level of triglycerides (2C class of recommendations). Data on the use of omega-3 PUFA for other indications are heterogenous, which can be partially explained by using different form and doses of the drugs.

[The Valsalva load test and spectral tracking echocardiography effectiveness in the diagnosis of heart failure with preserved left ventricular ejection fraction].

Aim      To determine the applicability of speckle-tracking EchoCG (STE) and the Valsalva maneuver for diagnosis of heart failure with preserved left ventricular ejection fraction (CHFpEF).Material and methods  Transthoracic STE with simultaneous electrocardiogram (ECG) recording was performed for patients with CHFpEF and healthy sex- and age-matched subjects (control group) at rest and during the Valsalva maneuver. The study was conducted in compliance with standards of Good Clinical Practice and principles of the Helsinki Declaration. The study protocol was approved by the Ethical Committee of the St. Petersburg State University.Results During the Valsalva maneuver, deviations of both global and segmental myocardial strain were more pronounced than at rest. In patients of the study group performing the Valsalva maneuver, LV end-diastolic volume and LV end-systolic volume (99 %) were increased. Heart rate was considerably reduced (significance of difference >99%) in patients with CHFpEF during the Valsalva maneuver compared to the control group. The increased predictive value of these parameters during the Valsalva maneuver can justify the inclusion of this method in early detection and prognostic assessment of CHFpEF.Conclusion      Speckle-tracking EchoCG with the Valsalva maneuver is a noninvasive, generally available, and easily reproducible outpatient method for diagnosis of CHFpEF.

[Motivational interviewing of older patients to participate in self-management programs for chronic obstructive pulmonary disease.]

The aim of this work is to create a methodology for the selection of older patients with a high degree of motivation to manage their disease in COPD. An algorithm for assessing the patient's motivation has been developed, consisting of 2 steps: a motivational interview and a calculation of motivational potential (MP). The interview is conducted using a questionnaire consisting of 4 blocks. Motivational potential is calculated as the sum of the influence contributions of blocks with selected weighting coefficients. The results of the MP potential assessment allow stratifying patients for participation in self-management programs into 3 psychotypes: motivated (MP≥0,5), unmotivated (MP≤0,25) and undecided (0,25≤MP≤0,5). To determine MP, 144 patients with COPD were interviewed: 111 men, mean age 68,5±4,6; women - 33, mean age 71,2±3,4 (minimum - 60 years, maximum - 75 years). The average duration of the disease was 5,48±1,2 years. 117 patients had stage 3 COPD, 27 patients had stage 2. It was found that 49/34% of patients have MT of 0.5 or more, 76/52,8% have 0,25 to 0,5, and 19/13,2% are unmotivated patients (MT<0,25). The proposed algorithm for assessing the motivational potential is distinguished by the simplicity of selecting elderly patients for the implementation of self-management programs in COPD.

[Applicability of the load dynamometric test and speckle tracking echocardiography in the heart failure with preserved ejection fraction diagnosis].

Aim    To compare myocardial deformation properties in patients with heart failure (HF) with preserved left ventricular ejection fraction (HFpEF) and in healthy volunteers at rest and during a dynamometric test; to determine a possibility of using this method for diagnosing HSpEF.Material and methods    STE with simultaneous electrocardiogram recording was performed for patients with HSpEF and healthy volunteers of the control group at rest and during a dynamometric test. The subjects were instructed to maintain a submaximal compression of a hand dynamometer for 3 min and to apply a maximum effort during the last 30 sec while continuing to breathe regularly. Concentrations of markers for myocardial injury and HF were measured. Statistical analytical methods are provided in Results. For other calculations, a MS Office (Microsoft Excel) application software package was used.Results    Differences in myocardial deformation variables between healthy volunteers and HF patients were more obvious during exercise, including changes of the variables from the resting values. As compared with the control group, patients with HFpEF had considerable deviations of the heart rate and the left ventricular global longitudinal strain (GLSLV) (significance of differences calculated with ANOVA was higher than 95% and 80%; p<0.05 and p<0.2, respectively). Patients with a significant change in the strain, regardless of the direction of the change, showed a decrease in the left ventricular ejection fraction (EFLV) during the test with a probability above 95% according to the Fischer test. Also, patients with HFpEF had higher concentrations of N-terminal pro-brain natriuretic peptide and symptoms of HF. Compared to evaluation of overall GLSLV, calculation of deformation variables by segment detected more differences between patients with HFpEF and control subjects.Conclusion    STE with a dynamometric test is an effective, noninvasive method for diagnosing HFpEF that is easy to perform in the outpatient conditions.

[Pathophysiological basis and diagnosis of the cardiovascular system damage caused by coronavirus infection].

This review focuses on the pathogenesis, most common clinical manifestations, and methods for diagnosis of damages to the cardiovascular system in coronavirus infection. The search for studies to be reviewed included publications of Elsevier, PubMed, and Web of Science resources by the key words "COVID-19", "myocarditis", "coronavirus", and "myocardial injury". The clinical presentation of coronavirus infection can include acute heart failure, myocardial injury, arrhythmias, pericarditis, venous thromboembolism, and microcirculatory dysfunction. Since symptoms of this pathology are non-specific, it is important to pay attention to monitoring of clinical laboratory and instrumental indexes for early differential diagnosis of cardiovascular disease. In all cases of parameter deviation from the normal range, cardiovascular complications of COVID-19 should be suspected. Measures should be taken for specifying the occurrence and severity of cardiac and/or vascular injury, and approaches should be developed for comprehensive treatment or prevention of these conditions.

[Significance of the echocardiographic evaluation of left atrial myocardial strain for early diagnosis of heart failure with preserved ejection fraction].

This systematic review is based on 19 studies from Elsevier, PubMed, Embase, and Scopus databases, which were found by the following keywords: LA strain (left atrial strain), STE (speckle tracking echocardiography), HF (heart failure), and HFpEF (heart failure with preserved ejection fraction). The review focuses on results and conclusions of studies on using the 2D echocardiographic evaluation of left atrial (LA) myocardial strain for early diagnosis of HFpEF in routine clinical practice. Analysis of the studies included into this review showed a significant decline of all LA functions in patients with HFpEF. Also, multiple studies have reported associations between decreased indexes of LA strain and old age, atrial fibrillation, left ventricular hypertrophy, left and right ventricular systolic dysfunction, and LV diastolic dysfunction. Thus, the review indicates significant possibilities of using indexes of LA strain in evaluation of early stages of both systolic and diastolic myocardial dysfunction. Notably, LA functional systolic and diastolic indexes are not sufficiently studied despite their growing significance for diagnosis and prognosis of patients with HFpEF. For this reason, in addition to existing models for risk stratification in this disease, including clinical characteristics and/or echocardiographic data, future studies should focus on these parameters.

[Atrial Fibrillation and Diabetes Mellitus: the Control of Thromboembolic Risk].

Atrial fibrillation is one of the most common concomitant diseases in patients with diabetes mellitus (DM). Meta-analyses of multiple studies have shown that the risk of AF is higher for diabetic patients with impaired glucose homeostasis than for patients without DM. Patients with AF and DM were younger, more frequently had arterial hypertension, chronic kidney disease, heart failure, and ischemic heart disease, and stroke and were characterized with a more severe course of AF. The article discusses possible mechanisms of the mutually aggravating effects of DM and AF, scales for evaluating the risk of bleeding (CHADS2, CHA2DS2­VASc, HAS-BLED), and the role of anticoagulants. A meta-analysis of 16 randomized clinical studies, including 9 874 patients, has demonstrated the efficacy of oral anticoagulants in prevention of stroke with an overall decrease in the relative risk by 62 % compared to placebo (95% confidence interval, from 48 to 72 ). For prevention of complications in patients with AF and DM, current antithrombotic therapies can be used, specifically the oral factor Xa inhibitor, rivaroxaban, which is the best studied in patients with AF and DM and represents a possible alternative to warfarin in such patients.

[Cardiovascular Pathology in Patients With COVID-19].

In the recent months of the COVID-19 pandemics, the cardiological society has faced a new challenge, myocardial injury by the coronavirus infection. According to statistics, 20-40% of hospitalized patients have chest pain, heart rhythm disorders, heart failure, and sudden cardiac death syndrome. This review focuses on recent studies and clinical cases related with this issue.

[Possibilities for predicting of cardiac arrhythmias and conductivity disorders in former athletes.]

In order to analyze the relationship between the athletic qualification and syndrome of cardiac rhythm and conductivity disturbances in former athletes, a retrospective analysis of medical records of 39 male former athletes with cardiovascular complaints (mean age 61,6±11,3 years, mean duration of career in sports 23,9±17,3 years, mean duration of post-athletic period 20,1±9,9 years) was carried out. The patients were screened for cardiac arrhythmias and underwent echocardiography. The overall prevalence of sustained paroxysms of atrial fibrillation was 42%, increasing with the athletic qualification. Ryan grade 4b-5 premature ventricular contractions were found in 14% of patients. 3 parameters were found to be the independent predictors of arrhythmias in former athletes, i. e. athletic qualification, multifocal atherosclerosis (as an anti-risk factor), and age. The coefficient of determinance for the created prognostic model reached 43%. Further prospective studies are needed to validate an algorithm.

[Pathogenetic mechanisms of development of myocardial pathology in patients with malignant tumors: the current state of the problem].

The myocardium, which has a high metabolic activity, responds to metabolic disorders and energy imbalance induced by a growing malignant tumor. In addition, the tumor itself can produce substances that directly affect metabolic processes and the life cycle of cells not involved in the neoplastic process, including cardiomyocytes. This review summarized and systematized current data on individual aspects of detrimental effects of oncogenes and tumor-related factors on the heart muscle and morpho-functional changes in the cardiovascular system of oncology patients. Also, the authors described in detail development of these pathogenetic mechanisms.

[Myocardial Strain Properties in Patients with Chronic Heart Failure].

Chronic heart failure is the cause of hospitalization of every fifth cardiological patient. Number of patients with heart failure symptoms that have preserved or intermediate left ventricle ejection fraction increases, i.e. grows portion of diastolic heart failure grows. Gray scale myocardial strain techniques provide an opportunity to detect myocardial dysfunction on early stages when absence of clinically significant symptoms are absent and conventional echocardiography is not informative. The goal of this study is to review parameters of myocardial strain and its clinical applicability in patients with chronic heart failure.

[Structural and Functional Characteristics of the Heart in Patients With "Constrictive", "Pseudo-Normal" and "Restrictive" Types of the Left Ventricular Diastolic Dysfunction].

PURPOSE: to study structural functional characteristics of the heart in patients with various types of abnormalities of diastolic function (DF) based on data obtained at stress echocardiography (stress EchoCG) and echocardiographic indexes of myocardial deformation. MATERIALS AND METHODS: We included in this study 110 patients with hypertensive disease (HD), clinically manifest chronic heart failure (CHF), and abnormal DF of the left ventricle (LV) in the absence of coronary artery stenosis. All patients underwent standard clinical and laboratory examination, EchoCG with measurement of 3­dimensional global longitudinal strain (GLS), and stress EchoCG on treadmill with evaluation of DF parameters. RESULTS: In the group with abnormal relaxation in patients with Е/e' >13 left atrial (LA) passive emptying fraction and distensibility index (27.1±14.5 and 127.8±96.1 %, respectively) were significantly smaller than in other patients of this group (34.8±14.2 и 207.7±86.8 %, respectively; р13 during exercise had lower LA passive emptying fraction and distensibility index (р13 during exercise, degree of reduction of LV contractility was similar irrespective of type of DF abnormality. In patients with different degrees of DF derangements (abnormal relaxation, transitional or restrictive type) Е/e' >13 during exercise was accompanied by similar lowering of mitral annular systolic velocity at rest (7.1±1.58, 6.9±1.13, and 6.79±0.93 cm / s, respectively). There were also no significant differences between these groups in values of 3­dimensional GLS (-11.2±1.5, -10.4±0.94, and -11.8±1.97 %, respectively). CONCLUSION: Elevation of LV filing pressure during stress EchoCG evidence for non-homogeneity of groups of patients with different degrees of DF abnormalities, presence of deeper structural-functional changes of the cardiovascular system, accompanied by reduction of myocardial contractility as well as LA reservoir and pump function. The use of stress EchoCG for evaluation of parameters of myocardial deformation allows to improve diagnostics of CHF in patients with preserved LV ejection fraction and directs to determination of criteria of preclinical manifestations of CHF.

[Chronic Heart Failure and Diabetes Mellitus: Pathogenesis and Possibilities of Treatment].

In this article we present data of scientific studies of prevalence of diabetes mellitus (DM) among patients with chronic heart failure (CHF), pathogenetic and risk factors of CHF development patients with DM (hyperglycemia, elevated body mass index, age, ischemic heart disease, nephropathy, proteinuria, DM duration, etc.). The article also contains results of analysis of mortality of patients with and without DM in dependence of ejection fraction value. After characterization of drugs for treatment of CHF in general and specifically in patients with DM we make focus on perspective directions in treatment of this group of patients. Sodium-glucose co-transporter 2 (SGLT2) inhibitors can be effective in patients with DM and CHF, in the first place empagliflozin with proven positive cardiac effects. In obese patients with and without DM efficacy of treatment at the background of lifestyle modification with the help of weight reduction, physical exercise, diet etc has been shown to be effective. In addition, there are data on positive effects of metformin which in patients with CHF and DM lowers availability of energy substrate at the account of reduction of volume of endogenous glucose.

[Endovascular Treatment of Critical Аоrtic Stenosis: Current State of the Problem and Perspectives].

The article contains the review of current understanding of the etiology and pathogenesis of degenerative aortic stenosis, approaches to surgical treatment depending on various factors, e. g. severity of defect and comorbidity, description of endovascular techniques (balloon valvuloplasty and transcatheter aortic valve implantation), and features of the selection of patients for these procedures. The authors also present assessment of results of operations performed from 2011 to 2016 in the city hospital № 2 in Saint-Petersburg. They analyze data from 72 high-risk aortic stenosis patients aged 81±6 years treated with transcatheter aortic valve implantation. In 68 out of 72 patients (94.4 %) clinical improvement was achieved with reduction of dilation of left ventricular cavity, decrease of functional class of heart failure, and decrease of mean pressure gradient across the aortic valve. A conclusion is made that these results confirm advantages and perspectives of the use of endovascular methods of treatment in this complicated group of patients.

[Chronic Kidney Disease as Basis of High Thrombotic and Bleeding Risk in Patients With Atrial Fibrillation: Place of Oral Anticoagulants].

Chronic kidney disease (CKD) aggravates course of practically all diseases by worsening outcomes and hindering adequate treatment. Specificities of renal excretion of various drugs, changes of parameters of their pharmacokinetics and pharmacodynamics, nephrotoxic effects of drugs, tactics of drug therapy in conditions of CKD, terminal stage of kidney failure and dialysis are in the focus of attention of internists. To a greatest degree difficulties of drug therapy in CKD and associated clinical states refer to the group of anticoagulants. Kidney diseases and related complications of anticoagulant therapy served as stimulus for search for new pharmacological approaches in anticoagulation, which resulted in creation and elaboration of novel oral anticoagulants (NOACs). NOACs are characterized by rapid onset and cessation of action, predictable pharmacokinetics, low potential of interaction with drugs and foods. Indicators of efficacy and safety of NOACs are similar to those of warfarin. Nevertheless, hemorrhagic and thrombotic events constitute the basis of further theoretical and practical investigations. These complications also stimulate aiming at selection of safest and balanced medicines. In this article we present various aspects of use of direct oral anticoagulants mostly in patients with CKD associated with atrial fibrillation.

[The influence of personal history of athletic activity on clinical course of cardiovascular diseases in former athletes.]

In this article, the prevalence of cardiac arrhythmias and conduction disorders is evaluated in former athletes with established cardiovascular diseases compared to cohort with comparable demographic profile and prevalence of hypertension and atherosclerosis. It is shown that the group of former athletes had a higher prevalence of hemodynamically significant pauses of asystole (RR 2,94, p=0,044), SA node blocks (RR 5,51, p=0,02) and required implantation of a permanent pacemaker more frequently (RR 5,14, p=0,017). A higher level of sports performance and sports experience are associated with higher risk of atrial fibrillation, and a longer career in sports is associated with higher burden of arrhythmias and dilated atria. The frequency of occurrence of eccentric hypertrophy increased with increasing athletic experience and inversely linked with the period of deconditioning. The changes are most pronounced in elite athletes, mandating the screening of rhythm and conduction disturbances in this subpopulation.

[The Insufficiency Type of Metabolic Balance and Nutritional Status in Patient With Heart Failure].

A lot of data has been accumulated at present on the metabolic and nutritional insufficiency in patients with chronic heart failure (CHF). Researchers have noted an actuality of the study of nutritional and metabolic insufficiency in CHF patients as independent factors affecting the course of CHF and because of its relationship with triggers of inflammation, sympathetic-adrenal system, and markers of functional state of the cardiovascular system (CVS). In some works attention has been given to relationship of nutritional and metabolic insufficiency with autonomic regulation of cardiac rhythm. Attempts have been made to systematize obtained data, create contemporary pathophysiological portrait of CHF development and highlight prevailing mechanisms of progression of the disease. This review summarizes accumulated data on nutritional insufficiency in patients with CHF and systematizes metabolic changes according to types of metabolism and CHF functional class. We have also made an attempt of creating figurative representation of pathophysiological mechanism of development of nutritional insufficiency in CHF. We have emphasized the problem of inadequate knowledge on contribution of inflammatory markers in development of nutritional insufficiency especially in patients with I-II functional classes of CHF. We also present suggestions concerning strategy of studying nutritional insufficiency in CHF, its classification according to CHF functional class, stratification of risk factors of its development, and the methods of its prevention and correction.

[Myocardial metabolism and metabolic drugs].

The article describes the basics of myocardial metabolism during normoxia and ischemia. It contains a brief description of the various drugs that affect the metabolic status of myocardium.

[Modern principles of diagnostics of chronic cardiac insufficiency].

Chronic cardiac insufficiency manifests itself in a number of clinical syndromes with signs and symptoms characterized by low specificity and sensitivity. ESC and ACC/AHA experts propose to use brain natriuretic peptide (BNP) and/or N-terminal BNP propeptide (NT-proBNP) levels in combination with tissue velocity imaging (TVI) to facilitate diagnostics of this condition. BNP and NT-proBNP levels are highly specific and sensitive indicators of left ventricular myocardium overload while TVI reveals chronic cardiac insufficiency in the asymptomatic phase of its development. Q-analysis of TVI provides data on global and local myocardial contraction and relaxation and allows objective quantitative evaluation of these functions in lieu of less accurate subjective characteristic. A number of cohort studies have confirmed high specificity and sensitivity of TVI, BNP and NT-proBNP levels at the early stages of chronic cardiac insufficiency.

Genetic determinants of the efficiency of climatotherapy in patients with chronic heart failure.

We studied the dependence of climatotherapy effectiveness in patients with chronic heart failure (functional classes 0-II) on Ca(2+)-ATPase, phospholamban, beta1-adrenoceptor, and insulin-like growth factor 1 gene polymorphisms and possible interaction of these genes during the realization of the effect of climatotherapy. The effectiveness of climatotherapy depended on polymorphism of the studied genes; the maximum effect was attained in patients with the GG polymorphism of the Ca(2+)-ATPase gene, GT polymorphism of the phospholamban gene, ArgGly polymorphism of the beta1-adrenoceptor gene, and 19/19 polymorphism of the insulin-like growth factor 1 gene. We demonstrated additive interaction of Ca(2+)-ATPase and beta1-adrenoceptor genes during the realization of the cardiotonic effect of climatotherapy.