[Summary of the 2023 European Society of Cardiology clinical guidelines on the management of cardiovascular disease in patients with diabetes mellitus].

The prevalence of cardiovascular diseases (CVDs) is well known. According to the World Health Organization (WHO), almost 18 million people die from CVDs worldwide every year, accounting for 31% of all causes of death [1]. CVDs often develop concomitantly with diabetes mellitus (DM), with approximately 20% of cardiovascular deaths attributed to elevated blood glucose levels [2]. Notably, CVDs are the leading cause of death among patients with type 2 diabetes (T2DM). Based on data from the Federal Register of Diabetes 2022 in Russia, chronic heart failure was the direct cause of death in 24.2% of T2DM cases, followed by acute heart failure (13.1%), cerebrovascular events (10.0%), and myocardial infarction (3.7%) [3].The pathophysiological interplay between atherosclerotic cardiovascular disease and DM has led to a situation where cardiologists are increasingly involved in the treatment of patients with DM, while endocrinologists are encountering a growing number of patients with CVDs. This association has become so apparent that in a recent article published in the European Journal of Cardiology, Yu. Braunwald speculated about the emergence of a new subspecialty - diabetocardiology [4]. Unfortunately, experts predict that the global number of diabetic patients will reach 783 million [5].Recent data on the CV benefits of certain hypoglycemic drugs (primarily, certain SGLT2 inhibitors, several GLP-1 receptor agonists, and a novel non-steroidal mineralocorticoid receptor antagonist finerenone) prove the need for a unified interdisciplinary approach to managing CVDs and DM.Given the importance of integrated and coordinated efforts in managing patients with CVD and DM, the Task Force of the -European Society of Cardiology (ESC) updated, formulated, and published clinical guidelines on the treatment of CVD in diabetic patients in 2023 [6]. This article provides a concise overview of the key provisions outlined in the guidelines.

Clinical, Anamnestic, and Demographic Characteristics of Patients with Myocardial Infarction in Russian Federation According to the Russian Registry of Acute Myocardial Infarction - REGION-IM.

AIM: Based on data from the Russian REGION-MI registry, to characterize patients with myocardial infarction (MI) hospitalized in Russian hospitals, describe their historical, demographic, and clinical characteristics, and compare the results with the data of previous Russian and international registries of acute coronary syndrome. MATERIAL AND METHODS: REGION-MI is a multicenter prospective observational study. The follow-up period was divided into three stages: during the hospital stay, at 6 and 12 months after the inclusion in the registry. Demographic and historic data and information about the present case of MI were entered into the patient's individual record card. RESULTS: The median age of all patients was 63 years; 68% of patients were men. The mean age of women was older than that of men. Among all MI cases, 70% were ST-segment elevation myocardial infarction (STEMI). Patients with non-ST-segment elevation myocardial infarction (NSTEMI) were older and had more comorbidities than patients with STEMI. The median time from the first symptoms to ECG recording was two hours, and from the first symptoms to CAG 7 hours. CAG was performed in 91% of patients with STEMI and 84% of patients with NSTEMI. Stenting was performed in 69% of patients. Although many patients had a complicated cardiovascular history, at the time of admission only 31.5% of patients were taking at least one drug from the groups of antiplatelets, oral anticoagulants, statins, and beta-blockers. CONCLUSION: Patients with MI in the Russian Federation are younger than patients with MI in European countries. Among the clinical and historical characteristics, conspicuous is the presence of modifiable risk factors in many patients, as well as the presence of a previous diagnosis of ischemic heart disease. Furthermore, a small proportion of patients took statins, antiplatelet agents or anticoagulants at the outpatient stage, which indicates a great reserve of both primary and secondary prevention of cardiovascular diseases in the Russian Federation. The delayed seeking medical help is also noticeable, which indicates the need for increasing the public awareness of the symptoms of MI and the importance of timely hospitalization.

[Features of the Reperfusion Therapy for ST-Segment Elevation Myocardial Infarction According to the Russian Registry of Acute Myocardial Infarction - REGION-IM].

AIM: Based on data from the Russian REGION-IM registry, to study the features of reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI) in real-life clinical practice. MATERIAL AND METHODS: REGION-IM is a multicenter prospective observational study. The observational period is divided into 3 stages: during the stay in the hospital and at 6 and 12 months after inclusion in the registry. The patient's records contain demographic and history data; information about the present case of MI, including the time of the first symptom onset, first contact with medical personnel, and admission to the hospital; coronary angiography (CAG) data, percutaneous coronary intervention (PCI) data, and information about the thrombolytic therapy (TLT). RESULTS: Reperfusion therapy was performed in 88.9 % of patients with STEMI. Primary PCI (pPCI) was performed in 60.6 % of patients. The median time from the onset of symptoms to pPCI was 315 minutes [195; 720]. The median time from ECG to pPCI was 110 minutes [84;150]. Isolated TLT was performed in 7.4 %, pharmaco-invasive treatment tactics were used only in 20.9 % of cases. The median time from ECG to TLT (prehospital and in-hospital) was 30 minutes [10; 59], whereas the median time from ECG to prehospital TLT was 18 minutes [10; 39], and in 63 % of patients, TLT was performed more than 10 minutes after diagnosis. PCI followed TLT in 73 % of patients. CONCLUSION: The frequency of reperfusion therapy for STEMI in the Russian Federation has increased considerably in recent years. The high frequency of pPCI is noteworthy, but the timing of pPCI does not always comply with clinical guidelines. The results of this registry confirm the high demand for pharmaco-invasive strategies in real-life clinical practice. Taking into account geographical and logistical features, implementing timely myocardial reperfusion requires prehospital TLT. However, the TLT frequency in the Russian Federation is still insufficient despite its proven maximum effectiveness in the shortest possible time from the detection of acute MI.

Features of Parenteral Anticoagulant Therapy in Patients With Myocardial Infarction According to the Russian Register of Acute Myocardial Infarction - REGION-IM.

Aim      To study specific features of the parenteral anticoagulant therapy for acute myocardial infarction (MI) in the Russian Federation and to evaluate the consistency of the prescribed parenteral anticoagulant therapy with the effective clinical guidelines.Material and methods  REGION-MI, the Russian rEGIstry for acute myOcardial iNfarction, is a multicenter observational study. This registry includes all patients admitted to hospitals with a documented diagnosis of ST-elevation acute MI (STEMI) and non-ST-elevation acute MI (NSTEMI) based on the criteria of the Forth Universal Definition of MI of the European Society of Cardiology. Risk of bleeding was assessed with the Academic Research Consortium for High Bleeding Risk (ARC-HBR) scale, and risk of major bleeding in patients with NSTEMI was additionally assessed with the CRUSADE scale.Results From November 01, 2020 through April 03, 2022, 5025 patients were included into the REGION-MI registry. At primary vascular departments, 70.5% of patients were administered unfractionated heparin (NFH); at regional vascular centers, 37.1 % of patients were administered NFH, 29.6 % enoxaparin, 20,2% NFH in combination with enoxaparin, 6.8 % fondaparinux, 4.2 % NFH in combination with fondaparinux, and 1.9 % nadroparin. At the prehospital stage, NFH was used as an anticoagulant support for the thrombolytic therapy (TLT) in 84% of patients, and low-molecular heparins (LMH) were used in 16 %. At the hospital stage, UFH was administered to 64.4 % of patients, and enoxaparin was administered to 23.9 % of patients. Among the patients who had undergone primary percutaneous coronary intervention (PCI), 40 % received NFH, 25 % enoxaparin, 22 % NFH in combination with enoxaparin, 7 % fondaparinux, and 4 % NFH in combination with fondaparinux. In conservative and invasive tactics of therapy for NSTEMI, NFH was also administered more frequently (43 and 43 %, respectively), followed by (according to frequency of administration) enoxaparin (36 and 34 %, respectively), NFH in combination with enoxaparin (10 and 16 %, respectively), fondaparinux (7 and 6 %, respectively), and NFH in combination with fondaparinux (3 and 1 %, respectively).Conclusion      According to the Russian registry of acute MI, REGION-MI, with all strategies for the treatment of MI, parenteral anticoagulants are not prescribed in full consistency with clinical guidelines. The most frequently used parenteral anticoagulant is NFH. Despite the high efficacy and safety of fondaparinux, the frequency of its administration remains unjustifiably low not only in the Russian Federation but also in other countries. The same can be said about the administration of enoxaparin to patients who had received TLT. Attention should be paid to physicians' awareness of recent clinical guidelines, to minimize the prehospital treatment with parenteral anticoagulants, to limit this treatment to the TLT support, and to provide continuity between all stages of medical care.

Features of antiplatelet therapy with P2Y12 receptor inhibitors in patients with myocardial infarction according to the Russian Register of Acute Myocardial Infarction REGION-MI.

Aim    To study specific features of administering platelet P2Y12 receptor inhibitors to patients with myocardial infarction (MI) in real-life clinical practice; to reveal a possible inconsistency of the therapy with clinical guidelines; to evaluate the patients' compliance with the medication at the outpatient stage; and to outline major direction for improving quality of the antiplatelet treatment.Material and methods    REGION-MI is a multicenter prospective, observational study. The observational period is divided into 3 stages: during the stay in the hospital and at 3 and 12 months following the inclusion into the registry. Information about the drug therapy (used at the time of hospitalization, administered before the hospitalization, received in the hospital, and prescribed at discharge from the hospital) was recorded in the patient's individual registration card. Information about the antiplatelet treatment at 6 months following enrollment into the study was obtain by phone.Results    The study included 4 553 patients. Dual antiplatelet therapy was administered after MI to 94.4 % patients: clopidogrel was administered to 52 %, ticagrelor to 42.2 %, and prasugrel to 11 patients (0.2 %). Ticagrelor was administered significantly more frequently in ST segment elevation myocardial infarction (STEMI) than in NSTEMI, 45 % and 33 %, respectively (p<0.001); clopidogrel was also administered more frequently to patients with STEMI than with NSTEMI, 59 % and 50 %, respectively. According to ARC-HBR criteria, in MI and a high risk of bleeding, clopidogrel was administered more frequently than ticagrelor (p <0.001). Ticagrelor was significantly more frequently administered to patients with MI and a low risk of bleeding than to patients with a high risk (p<0.001). In STEMI and a low risk of bleeding, ticagrelor was administered somewhat more frequently than clopidogrel, 56 % and 44 %, respectively (р<0.05). In NSTEMI and a low risk of bleeding, clopidogrel was administered more frequently than ticagrelor, 53 % and 47 %, respectively (p<0.05). At 6 months post-MI, 94 % of patients continued taking one of the P2Y12 inhibitors.Conclusion    According to data of the REGION-MI registry, the frequency of administering P2Y12 inhibitors to patients with acute MI was high, and the patients' compliance with this therapy was high at 6 months following MI. Although ticagrelor (the most available drug of all powerful platelet P2Y12 receptor inhibitors) has been prescribed more frequently in the recent years, a definite reserve exists for increasing the frequency of its administration. This is particularly important with a low risk of bleeding and the absence of requirement for anticoagulants. Thus, the prognosis for MI patients can be considerably improved.

The prevalence of hyperlipidemia and features of lipid-lowering therapy in patients with myocardial infarction according to the Russian register of acute myocardial infarction REGION-MI.

Aim      To study the prevalence of hyperlipidemia in patients with myocardial infarction (MI) in the Russian Federation; to assess the compliance with clinical practice guidelines of the lipid-lowering therapy prescribed upon discharge from the hospital; and to determine the number of patients who are indicated for the combination lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) goal.Material and methods  REGION-MI is Russian rEGIstry Of acute myocardial iNfarction, a multicenter, retrospective and prospective observational study. The observation period was divided into 3 stages: observation during the stay in the hospital and at 6 and 12 months after the inclusion in the registry. Plasma total cholesterol (TC) and LDL-C were measured in all patients on admission. Evaluation of the prescribed lipid-lowering therapy included the intensity of the treatment.Results The study included 3 620 patients; 62.4 of them had hyperlipidemia on admission. Mean TC on admission was 5.29 mmol/l and LDl-C level was 3.35 mmol/l. Upon discharge, 95.4% of patients after myocardial infarction continued on or were prescribed statin therapy; ezetimibe was prescribed to 1.22% of patients. Patients with an extremely high level of LDL-C >5 mmol/l accounted for 10.7% of patients with hyperlipidemia. The target level of LDL-C ≤1.4 mmol/l cannot be achieved with the statin and ezetimibe combination therapy in these patients; drugs from the group of PCSK9 inhibitors are indicated for them.Conclusion      According to the data of the Russian registry of acute myocardial infarction, REGION-MI, a high incidence of hyperlipidemia is observed in patients with acute MI. Despite multiple studies that have proven the importance of achieving a low LDL-C level and good tolerance and safety of ezetimibe and PCSK9 inhibitors, the prescription frequency of combination therapy remains unreasonably low. Results of a simulation study that was conducted in Sweden and the data of the REGION-MI registry showed that PCSK9 inhibitors as a part of the combination therapy are indicated for many patients. The combination therapy is presently the most powerful type of lipid-lowering treatment that allows, in most cases, achievement of the LDL-C goal.

Registry of Acute Myocardial Infarction. REGION-MI - Russian Registry of Acute Myocardial Infarction.

Aim      To study features of diagnosis and treatment of acute myocardial infarction (AMI) in Russian hospitals, results of the treatment, and early and late outcomes (6 and 12 months after AMI diagnosis); to evaluate the consistence of the treatment with clinical guidelines; and to evaluate patients' compliance with the treatment.Material and methods  The program was designed for 3 years, including 24 months for recruitment of patients to the study. The study will include 10, 000 patients hospitalized with a confirmed diagnosis (I21 according to ICD-10) of ST segment elevation acute myocardial infarction (MI) (STEMI) or non-ST segment elevation MI (NSTEMI) based on criteria of the European Society of Cardiology Guidelines on Forth Universal Definition of Myocardial Infarction (2018). The follow-up period was divided into three stages: observation during the stay in the hospital and at 6 and 12 months following inclusion into the registry. The primary endpoint included cardiac death, nonfatal MI during the hospitalization and after one-year follow-up. Secondary endpoints were 6-months and one-year incidence of repeated MI, heart failure, ischemic stroke, clinically significant hemorrhage, unscheduled revascularization after discharge from the hospital, and the proportion of patients who continue on statins, antiplatelet drugs, and drugs of other groups for 6 months and 1 year.Results The inclusion of patients into the registry started in 2020 and will continue for 24 months. By the time of the article publication (June, 2021), more than 2,000 patients will be included.Conclusion      REGION-MI (Russian rEGIstry Of acute myocardial iNfarction) is a multicenter, retrospective and prospective observational cohort study that excludes any interference with the clinical practice. Results of the registry will help to analyze a real picture of medical care provided to patients with myocardial infarction and to schedule ways to improve the situation.

[The Risk of Developing Ischemic Stroke in Patients After Exacerbation of Ischemic Heart Disease].

Aim      To develop a model for evaluating the risk of stroke in patients after exacerbation of ischemic heart disease who were admitted to the hospitals included into a vascular program.Materials and methods This study included 1803 patients with acute coronary syndrome (ACS) from four institutions of Moscow, Kazan, Astrakhan, and Krasnodar where the vascular program was established. Mean age of patients was 64.9±12.78 years, 62,1 % of them were men. The patients were followed up for one year after the discharge from the hospital. External validation of the developed prognostic model was performed on a cohort of patients with ACS included into the RECORD-3 study.Results During the follow-up period, 42 cases of ischemic stroke were observed. The risk of ischemic stroke was associated with the presence of atrial fibrillation (odd ratio (OR) 2.640; р=0.037), diabetes mellitus (OR 2.718; р=0.041), and chronic heart failure (OR 7.049; р=0.011). Protective factors were high-density lipoprotein cholesterol >1 mmol/l (OR 0.629; р=0.041), percutaneous coronary intervention during an index hospitalization (OR 0.412; р=0.042), anticoagulant treatment (OR 0.670; р=0.049), and achieving the blood pressure goal (OR 0.604; р=0.023). The prognostic model developed on the basis of regression analysis showed a good predictive value (area under the ROC curve, 0.780), sensitivity of 80 %, and specificity of 64.6 %. The diagnostic value of other scales for risk assessment was somewhat lower. The area under the ROC curve was 0.692±0.0245 for the GRACE scale and 0.708±0.0334 for CHA2DS2­VASc. In the external validation of the scale based on data of the RECORD-3 study, the diagnostic value was lower although satisfactory as well (area under the ROC curve, 0.651); sensitivity was 78.9 %, and specificity was 52.3 %.Conclusion      The study resulted in development of a simple clinical scale, which will probably allow identifying groups at risk of stroke more precisely than with standard scales.

[External validation of the ORACLE bleeding risk score using the database of the RECORD 3 registry].

AIM: To validate a domestic scale for assessment risk of bleeding ORACUL (ОРАКУЛ) based on an independent sample of patients with acute coronary syndrome (ACS). MATERIALS AND METHODS: External validation of the ORACUL score was carried out using database of an independent observational study RECORD-3 which comprised data from all patients hospitalized for 1 month (march-april 2015) in 47 centers of 37 cities in 21 regions of Russia. Total number of included patients was 2370, mean age 64.2±11.96 years, 821 patients (34.6%) had ST-elevation, other patients - non-ST elevation ACS. RESULTS: The following bleeding events were registered in RECORD-3: bleedings during hospitalization (n=34, 1.43%), inhospital bleedings requiring withdrawal of antithrombotic treatment (n=16, 0.68%), inhospital bleedings, which required drug or surgical treatment or hemotransfusion (n=16, 0.68%). Forty eight hemorrhagic complications were registered during 6 months of observation after hospital discharge. Diagnostic value of the ORACUL score for estimation of risk of bleedings during index hospitalization was good (C-criterion 0.691±0.050; р<0.001), sensitivity of the model was 58.1%, specificity 79.9%. Earlier on the cohort of patients of the ORACUL study diagnostic value of the score for inhospital bleedings was found to be 0.777±0.046. Difference of diagnostic values was inessential. For estimation of the bleeding risk during 6 months of post discharge observation area under the ROC curve (C-criterion) was 0.628±0.045 (р=0.003), sensitivity and specificity of the model were 53.9 and 73.7%, respectively. On the ORACUL study cohort AUC 0.748±0.048 (р=0.071). CONCLUSION: External validation confirmed that statistical power of the OCACUL score is sufficient for prediction of bleedings during both periods of hospitalization and after hospital discharge.

[How "Real Life" Treatment of Patients With ST-Elevation Acute Coronary Syndrome Has Changed During Recent Several Years (Data From a Series of the Russian RECORD Registries)].

PURPOSE: to assess changes in the management of patient with ST-Elevation (STE) Acute Coronary Syndrome (ACS) which occurred during recent several years by means of comparing data from the series of Russian ACS registries RECORD - "old" (RECORD and RECORD-2, 2007-2011) and "new" (RECORD-3, 2015). RESULTS: Numbers of included patients were 967 and 868, proportion of invasive centers - 56 and 55 % in "old" and "new" registries, respectively. Most anamnestic characteristics of both populations (of old registries group and the new registry) were similar. In RECORD-3 compared with old registers level of troponins was significantly more often determined, median time from symptoms onset until seeking medical help and until hospitalization was higher, and significantly more patients were transferred directly to catheterization laboratory. There were no significant differences in rates of primary percutaneous interventions (PCI) and use of thrombolytic therapy (TLT) between "old" registries and RECORD-3: 36.3 vs. 39.0 % (р=0.24), 32.2 vs. 32.1 % (p=0.98), respectively. However, compared with RECORD (2007-2008) rates of primary PCI, prehospital TTL, use of pharmacoinvasive approach, and any PCI during hospitalization in RECORD-3 were significantly higher: 20 vs. 39 % (р.

[Relationship Between Degree of Coronary Vascular Bed Involvement and Characteristics of Stenting With Short-Term and Long-Term Outcomes in Patients With Acute Coronary Syndrome (Data of the RECORD-3 Registry)].

It was shown in this retrospective analysis of data from the Russian registry of acute coronary syndromes (ACS) RECORD-3 that compared with patients in whom coronary angiography revealed no hemodynamically significant (>50 %) stenosis, patients with such stenosis in one vessel (with single vessel disease - SVD) and especially in multiple vessels (with multi-vessel disease - MVD) had much more anamnestic and clinical factors of unfavorable prognosis. Rates of all cause death as well as composite of death and new myocardial infarction (MI) during hospitalization in patients without significant stenosis and those with SVD were not significantly different but rates of these outcomes among patients with MVD were significantly higher than among patients with SVD or without significant stenosis. Presence of MVD was associated with worse remote outcomes developed after discharge from hospital compared with absence of significant stenosis (rate of death, MI, and urgent revascularization was significantly higher for 6 and 12 months after ACS), and compared with SVD (rate of death, MI, and urgent revascularization was significantly higher for 12 months after ACS). During percutaneous coronary interventions bare metal stents were used 2 times more often than drug eluting stents. Implantation of 2 or more stents compared with implantation of 1 stent was associated with higher rate of unfavorable outcomes (composite of death, MI, and urgent revascularization) developed after hospital discharge during 12 months after onset of ACS.

Changes of Treatment of Patients With Non-ST Elevation Acute Coronary Syndrome in Clinical Practice During Recent Several Years (Data From a Series of the Russian RECORD Registries).

Erlikh A. D. on Behalf of Participants of the RECORD Registers. PURPOSE: to assess changes in the management of patient with Non-ST Elevation (NSTE) Acute Coronary Syndrome (ACS) which occurred in Russian hospitals during recent several years by means of comparing data from a series ofACS registries RECORD - "old" (RECORD and RECORD-2, 2007-2011) and "new" (RECORD-3, 2015). RESULTS: Numbers of included patients with NSTEACS were 1502 and 1485 in then "new" and "old" registries, respectively. "New" registry compared with "old" comprised more women (44 and 37%, respectively, p=0.0001). Portions of patients aged ≥ 65 years were not statistically different (51 and 47%, respectively, р=0.57). Time from onset of symptoms to hospital admission was longer (7.7 and 4.8 hours, р<0.0001), portion of patients hospitalized in invasive hospitals - higher (67 and 42%, р<0.0001), frequency of troponin level determination - higher (72 and 45%, р<0.00001), frequency of coronary angiography (CA) - higher (48 and 30%, р<0.0001), and of percutaneous coronary interventions (PCI) - higher (21 and 15%, p<0.0001) in the "new" than "old" registries. In invasive hospitals rates of CA, PCI during hospital stay, frequencies of detection of stenoses ≥ 50%, and rates of coronary stenting in the "new" and "old" registries were not statistically different. Rate of PCI during first 72 hours in patients with coronary stenoses ≥ 50% was higher in the "new" registry (48 and 40%, respectively, р=0.013). During hospital stay patients in the «new¼ registry significantly more rarely received acetylsalicylic acid, parental anticoagulants, nitrates, and more often - dual antiplatelet therapy (DAPT), fondaparinux, statins; while at hospital discharge they were more rarely prescribed ß -adrenoblockers, nitrates, and more often - DAPT, statins. Rates of death in "new" and "old" registries were not significantly different (2.5 and 3.4%, respectively, р=0.11) while sum of unfavorable outcomes (deaths + new myocardial infarctions) during hospital stay in the "new" registry was smaller (3.7 and 5.2%, respectively, р=0.042). Median length of inhospital treatment was 10.0 and 13.0 days (p<0.0001), portion of patients transferred from noninvasive hospitals for CA was 12.2 and 1.6% (р<0.0001) in "new" and "old" registries, respectively. CONCLUSION: Main changes in management of patients with NSTEACS occurring between conduct of "old" and "new" registries RECORD became more frequent hospitalization in invasive hospitals and transferal from noninvasive hospitals for coronary angiography, more frequent determination of troponin, use of DAPT. With this rate of invasive coronary procedures was not sufficiently increased and remained relatively low.

[Registry of Acute Coronary Syndromes RECORD-3. Characteristics of Patients and Treatment During Initial Hospitalization].

Acute Coronary Syndrome (ACS) Registries RECORD 1-2 (2007-2001) gave valuable information on management of ACS patients in Russia. RECORD-3 was carried out in March-April, 2015. Here we present characteristics of included patients (pts) and data on their treatment during initial hospitalization. MATERIAL AND METHODS: RECORD-3 recruited pts with suspected ACS consecutively hospitalized in participating hospitals (n=47, 55% "invasive") during 1 month. RESULTS: Number of included pts was 2370 (39% women, mean age 64.6 years), 72% were admitted to invasive hospitals, 37% had ST-elevation ACS (STEACS). Median "onset of symptoms - first medical contact" time was 3.4 (1.0-16.8) hours, "first medical contact - hospital admission" time - 1.5 (1.0-3.1) hours. Cardiac troponin was determined in 76% of pts. Coronary angiography was carried out in 70 and 46% of pts with STE and non-STE ACS, respectively. (16% of all patients hospitalized in "noninvasive" cetnters were transferred for angiography to invasive ones). Primary percutaneous coronary intervention (PCI) was performed in 39% of patients with STEACS (in 65% of them with "door to pPCI" time less or equal 90 min). Thrombolytic therapy (TLT) was administered to 32% of pts (in half of them prehospitally). Overall reperfusion therapy received 68% of pts. Among non-STEACS pts rate of PCI was 20% (1/3 of procedures within 2, 1/3 - >2-24hours). Inhospital antiplatelet therapy (APT) included aspirin (88%), clopidogrel (71%), ticagrelor (14%); 86% of pts received dual APT. Other medications were: unfractionated heparin (UFH, 47% [81% subcutaneously]), enoxaparin (13%), fondaparinux (10%), angiotensin converting enzyme inhibitors/sartans (81%), -adrenoblockers (84%), statins (87%). Mortality during hospitalization (median 10 days) was 10% in STE, and 5% in non-STE ACS. CONCLUSION: Inhospital management of RECORD-3 population was characterized by relatively low rates of pPCI, reperfusion therapy in STEACS, urgent PCI in non-STEACS. Preponderance of UFG including its subcutaneous use is of note. Use of other standard therapies appears satisfactory.

[The Study of Evidence Base for the Use of Lappaconitine Hydrobromide in Patients With Atrial Fibrillation].

Lappaconitine Hydrobromide (LH, allapinin) has been included by authors of National Guidelines on Diagnosis and Treatment of Atrial Fibrillation (AF), 2012 in the number of medications recommended for use in patients with AF for rhythm control. Moreover, LH is also included into the List of Vital and Essential Medicinal Drugs (VEMD) 2015. However, LH is not mentioned in corresponding guidelines of the European Society of Cardiology (ESC). Aim of the present review was to explore evidence base underlining use of LH in the context of AF and to understand reason for LH-related discrepancy between European and domestic guidelines. RESULTS: Literature search has indicated that efficacy of LH was assessed only in small open studies. None of prospective trials included more than 100 patients. For more than 25 years of presence on the market slightly more than 400 patients were administered LH in clinical studies. In the only trial, designated as randomized number of participants (only men younger than 60 years) was small and the comparator was quinidine that presently is not used for maintenance of sinus rhythm in AF. Another study referenced in domestic guidelines on management of AF was observational and not intended for comparison of antiarrhythmic activity of drugs. CONCLUSION: Design of studies reviewed as well as their results provide insufficient evidence supporting the use of LH for maintenance of sinus rhythm in routine management of AF. At present inclusion of LH in guidelines on AF management and in the List of VEMD appears unjustified.

[Prognostic value of left bundle brunch block in patients with acute coronary syndrome].

AIM: to assess rognostic value of ECG signs of left bundle brunch block (LBBB) using database of registries of acute coronary syndromes (ACS) RECORD 1 (2007-2008) and 2 (2009-2011). MATERIAL AND METHODS: Total number of included patients was 2452, 2321 patients (94.9%) had no signs of LBBB, for 5 patients (0.2%) there was no information on the presence of LBBB. Among 126 patients (5.1%) with LBBB it was designated as "new" in 72 (2.9%), "old" in 39 (1.6%), and of "unknown duration" in 15 (0.6%) patients. For further analysis we combined patients with "new" and "unknown duration" LBBB (n=87 [3.5%]). Among these patients 43 (49.5%) were considered as having ST elevation (STE) and 44 (50/5%) - non STE ACS. RESULTS: Patients with LBBB were significantly older, had more concomitant diseases, more severe course of ACS, and higher GRACE score. Patients with new LBBB irrespective of ACS type significantly less often received active drug therapy while reperfusion therapy was significantly less often used in patients with LBBB and diagnosed STE myocardial infarction. Unfavorable events such as cardiogenic shock, death, death and myocardial infarction during hospitalization occurred more often among patients with STEACS and new LBBB. CONCLUSION: Patients with ECG signs of LBBB at the background of ACS were characterized by severe clinical course of the disease and have unfavorable short term prognosis. However quality of hospital care of these patients was significantly worse compared with average quality of care of patients with ACS without LBBB.

[Comparison of data from registries of acute coronary syndromes RECORD and RECORD-2: management of patients and its results in noninvasive hospitals].

Positive changes are declared to occur during recent years in management of hospitalized patients with acute coronary syndromes (ACS) in Russia. Most of these changes are related to availability of invasive treatment. But considerable portion of patients (pts) are still treated in hospitals without facilities for invasive myocardial revascularization (noninvasive hospitals - NIHs). Aim of this study was to compare some characteristics of management of ACS in NIHs which participated in ACS registries RECORD (2007-2008, 8 NIHs from 6 cities; n=381) and RECORD-2 (2009-2011, 3 NIHs from 3 cities, n=680). Results. Groups of pts recruited in these NIHs had similar mean age and portion of women (67.6 and 66.5 years, 51.1 and 53.1 % in RECORD-2 and RECORD, respectively, p=0.64). Time from symptoms onset to hospitalization was shorter in RECORD-2 (3.2 vs 4.1 hours for ST-elevation [STE], =0.03; 4.0 vs 6.5 hours for non ST elevation [NSTE] ACS, <0.0001). Among RECORD-2 NSTEACS pts more had ST depressions (50.6 vs 28.7%, <0.0001), high risk of death according to GRACE score (39.1 vs 20.9 %, <0.0001), but less Killip class >II (15.0 vs 21.6%, p=0.025). No such differences existed among STEACS pts. Thrombolysis was more often used in RECORD-2 (62.6 vs 34.1%, <0.0001). Both STEACS and NSTEACS RECORD-2 pts more often received clopidogrel (63.5 vs 18.8%, p<0.0001, and 41.6 vs 11.1%, <0.0001, respectively). More NSTEACS RECORD-2 pts were given parenteral anticoagulants (93.4 vs 80.4%, <0.0001), low molecular weight heparins (23.4 vs. 3.4%, <0.0001) and fondaparinux (10.4 vs 0.7%, <0.0001), but still in 20% of NSTEACS RECORD-2 pts unfractionated heparin was given subcutaneously. Twenty RECORD-2 pts (2.9%) were transferred to invasive hospital but none during first 24 hours. There were no significant differences between registers in hospital mortality (20.0 vs 21.2%, =0.84; 4.2 vs 2.7%, =0.24 in STE and NSTE ACS pts of RECORD-2 and RECORD, respectively). Conclusions. Despite some improvement in management of pts occurring in 2-3 years NIHs mortality in STEACS remained very high. Numerically higher mortality in NSTEACS could be partially attributed to higher risk of RECORD-2 pts.

[Adherence to guidelines on management of acute coronary syndrome in Russian hospitals and outcomes of hospitalization (data from the RECORD-2 Registry)].

BACKGROUND: Complete following existing guidelines for management of acute coronary syndrome (ACS) is known to be associated with better outcomes. Partly this is explained by lesser adherence to recommendations in high risk patients. Aim of our study was to assess relationship between degree of following current guidelines and in hospital outcomes independently from initial assessment of risk. METHODS: Each key recommendation from guidelines issued between 2008 and 2011 (13 for STE ACS, 12 for NSTE ACS) was given weight of 1. Sum of these units constituted index of guideline adherence (IGA). IGA was retrospectively calculated for 1656 patients included in Russian independent ACS registry RECORD-2 (7 hospitals, duration 04.2009 to 04.2011). The patients were divided into 2 groups according to quartiles of IGA distribution: 1) low adherence group (quartiles I-II); 2) high adherence group (quartiles III-IV). RESULTS: In low adherence compared with high adherence group there were significantly more patients more or equal 65 years (=0.0007), with chronic heart failure [CHF] (<0.0001), previous stroke (<0.0001), atrial fibrillation [AF] (=0.0002), Killip class more or equal II (=0.0065), high risk of death by GRACE score (=0.035). Inhospital mortality was 9.3 and 2.4% in low and high adherence group, respectively (p<0.0001). The following independent predictors of inhospital death were identified: IGA quartiles I-II (odds ratio [OR] 4.0; 95% confidence interval [CI] 2.3-7.1; <0.0001), high GRACE score (OR 3.3; 95% CI 1.8-6.0; <0.0001), admission systolic BP less or equal 100 mm Hg (OR 3.1; 95% CI 1.8-5.4; <0.0001), admission serum glucose more or equal 8 mmol/l (OR 2.9; 95% CI 1.8-4.7; <0.0001), age more or equal 65 years (OR 2.3; 95% CI 1.3-4.0; =0.005), ST elevation more or equal 1 mm on first ECG (OR 1.7; 95% CI 1.1-2.5; =0.013). From groups with low and high adherence to guidelines we selected pairs of patients (n=588) with similar (or close) age, type of ACS, GRACE score, Killip class, presence of other important risk factors (CHF, AF, previous stroke), and formed 2 equal subgroups without significant differences in important demographic, anamnestic, clinical and laboratory data. Hospital mortality was 7.8 and 2.7% in low and high adherence subgroup, respectively (p<0.0001). CONCLUSIONS: In RECORD-2 ACS registry low adherence to guidelines was more frequent among high risk patients and was independent predictor of inhospital death. Association between degree of guidelines adherence and outcomes persisted after equalizing groups by some factors of risk of mortality.

[First Moscow "snapshot" register of acute coronary syndromes: characteristics of patients, management and outcomes during hospitalization].

AIM: To characterize inhospital management of patients (pts) with acute coronary syndromes (ACS) using data from Moscow snapshot registry of hospitalized pts with ACS. METHODS: The registry included data on consecutive pts with ACS hospitalized with label ACS in coronary care units (CCU) or equivalents within 24 hours (h) after onset of symptoms during one week in November 2013. Data was obtained from 32 (17 percutaneous coronary intervention [PCI] capable or "invasive") city hospitals officially treating ACS patients. RESULTS: Total number of pts--584 (mean age 66.4 +/- 13.1 years; > or = 65 years 54.6%; women 44.2%; registered in invasive hospital--42%). Portions of pts labeled ST-elevation (STE) and non ST-elevation (NSTE) ACS--27.9 and 72.1%, respectively. Portion of pts hospitalized within 1-st 12 h after symptoms onset--65.2% (68% among STEACS pts). Reperfusion therapy--44.8% of pts with STEACS (54.3% in invasive and 21.3% in noninvasive hospitals, p < 0.0001). Thrombolysis (TI) was performed in 19% of STEACS pts (41.9% prehospital). In hospital median admission to initiation of TI time--0.30 h (quartiles I-III 0.15-0.30 h). Rate of primary (p) PCI in STEACS pts--overall 25.8%, in invasive hospitals--36.2%, in pts admitted within 12 h--31.4 and 40.5%, respectively. Median admission--pPCI initiation time--1.35 h (quartiles I-III 1.00- 2.15 h). PCI rate among NSTEACS pts--6.2 overall and 20.5% in invasive hospitals (14.7% during 1st 72 h). Medication in hospital: aspirin--95.2, clopidogrel--70.7, ticagrelor--4.3%, parenteral anticoagulants--88.9 (1/3 unfractionated heparin [UFH] subcutaneously), ACE inhibitors--83.3, beta-blockers--86.3, statins--58.3%. Mean duration of hospital stay--13.2 +/- 4.4 days. Transferral from noninvasive to invasive hospital for urgent coronary intervention--4.5 and 3.5% of STE and NSTE ACS pts, respectively. Hospital mortality--12.4 and 1.9% among pts registered as STE and NSTEACS, respectively. Cardiac troponins measured--42% (39% among STEACS) pts. CONCLUSION: The following features of inhospital management of pts diagnosed as ACS at CCU (or its equivalent) admission could be object of improvement: low rate of reperfusion therapy and use of PCI, long interval between admission and initiation of PCI, insufficient use of some standard medications, frequent use of subcutaneous UFH, rare transferal of PCI eligible pts from noninvasive to invasive hospitals. However existing management was associated with reported low hospital mortality in patients labeled as NSTEACS.

[Prehospital management of patients with acute coronary syndrome in Moscow. Data of the first Moscow "snapshot" register].

AIM: To characterize the state of prehospital management of patients with acute coronary syndromes (ACS) using data from Moscow snapshot registry of hospitalized patients with ACS. METHODS: The registry included data on consecutive patients with ACS admitted to coronary care units or their equivalents of participating hospitals within 24 hours after onset of symptoms during one week in November 2013. Data was obtained from 32 (17 PCI capable or "invasive") city hospitals officially treating ACS patients. Data concerning prehospital stage was collected by hospital physicians. RESULTS: Among 584 patients included in the registry 88.8% were brought by ambulances. Time (median) from onset of symptoms to call for medical aid was 2.4 h, to hospitalization - 4.3 h, from call for medical aid to hospitalization--1.6 h. Calculated approximate time of contact of ambulance staff with patient at site of attack (the latter time minus official time to arrival and transportation time) was more than 50 min. Referral diagnoses were myocardial infarction (MI) in 29.3, unstable angina in 48.4, other acute conditions in 22.3% of patients. Among patients referred as unstable angina about 49% were diagnosed as MI during hospitalization. Referral diagnosis of ambulance physicians did not appear among independent predictors of inhospital death or new MI (ST depressions, Killip class > or = ll, high GRACE score). Rate of prehospital thrombolysis was 8.0% among all patients diagnosed in hospital as ST elevation (STE) ACS (10.8% among STEACS patients admitted within 12 h of symptoms). There were significantly less patients older than 65 years among those subjected compared with not subjected to prehospital thrombolysis (23.1% vs. 59.6%, respectively; p = 0.024). Clopidogrel (mostly 300 mg) and recommended loading dose of aspirin were given to 70.9 and 51% of patients, respectively. Unfractionated heparin and enoxaparin were given to 49.4 and 7.5% of all patients, respectively. Inhospital bleeding rate was significantly higher in patients phehospitally treated with anticoagulants. CONCLUSION: The following characteristics of prehospital management of patients diagnosed as ACS at hospital (CCU) admission could be object of improvement: long time of contact of ambulance staff with patients; attempts to diagnose (exclude) MI associated with unjustified referral to noninvasive hospitals; preferential use of thrombolysis in younger patients; relatively rare use of guideline recommended doses of aspirin and clopidogrel. Of note is association of inhospital bleedings with prehospital administration of anticoagulants.

[Acute non ST-elevation coronary syndrome in real practice of hospitals in Russia. Comparative data from RECORD 2 and RECORD registries].

AIM: to compare data on pre- and in hospital treatment of non ST-elevation (NSTE) acute coronary syndromes (ACS) in Russian ACS registers RECORD (recruitment from 11.2007 to 02.2008) and RECORD-2 (from 04/2009 to 04.2011). MATERIAL: Four of 7 hospitals participating in RECORD-2 were invasive (57.1% vs. 55.6% in RECORD). In RECORD-2 10-30 consecutive patients with NSTEACS were included monthly in each center; recruitment in RECORD was described elsewhere. RESULTS: Mean age of patients was similar in two registries. Portion of women was significantly higher in RECORD-2 (42.9% vs. 26.0% in RECORD; <0.0001). Although markers of necrosis were measured in higher proportion of patients in RECORD-2, frequency of troponin determination was not significantly different (47.0 vs. 43.5% in RECORD; =0.64). Patients in RECORD-2 more frequently received prehospital aspirin (51.6 vs 33.5%; <0.0001), aspirin in recommended initial dose 160-325 mg (64.3 vs. 47.1%; =0.03), and clopidogrel during hospitalization (47.0 vs. 27.6%; <0.0001). Rates of in hospital use of parenteral anticoagulants in both registries were similar, but among anticoagulants in RECORD 2 proportion of fondaparinucs became noticeable (9.5%) and that of low molecular weight heparin (LMWH) became significantly higher (21.2 vs. 11.6% in RECORD). Almost one third of patients in RECORD-2 who were treated with unfractionated heparin (UFH) received it subcutaneously. About half of patients treated with intravenous infusion of UFH received it for less than 48 hours. Although higher proportion of patients hospitalized in invasive hospitals were subjected to diagnostic coronary angiography in RECORD-2 (80.8 vs. 54.3% in RECORD; <0.0001) differences between registries in rates of percutaneous coronary interventions (PCI) (all - 37.3 vs. 29.9%; =0.051; first 72 hours - 22.7 vs. 24.8%; =0.55), and coronary artery bypass graftings (5.6 vs. 5.8%; =0.12) were not significant. There were no significant differences in rates of any in hospital unfavorable events. Analysis of treatment and outcomes in groups of high risk patients (GRACE score >140) gave results close to those in all patients except mortality which was statistically similar but numerically higher in RECORD-2 (9.3 vs. 7.9% in RECORD; p=0.68). CONCLUSION: Comparison of data of 2 limited NSTEACS registers conducted with interval of about 2 years showed only modest shift towards fulfillment of contemporary recommendations which was not associated with increase in rates of PCI and improvement of outcomes especially in high risk patients.