Chronic obstructive pulmonary disease in patients with coronary heart disease worsens long-term prognosis after percutaneous coronary interventions.

Aim    To evaluate the incidence rate of major adverse cardiovascular events (MACVE) in the long-term following percutaneous coronary interventions (PCCI) in patients with acute and chronic ischemic heart disease (IHD) and the contribution of concurrent chronic obstructive pulmonary disease (COPD) to the long-term prediction.Material and methods    This prospective cohort study included 254 patients with IHD and concurrent COPD and 392 patients with IHD without COPD. PCCI was performed in all patients: for acute coronary syndrome in 295 patients and for chronic IHD in 351 patients. The follow-up period lasted for up to 36 months. The outcome was a composite endpoint, MACVE, that included cardiovascular death, myocardial infarction, stroke, repeated unscheduled myocardial revascularization (MR), and the time to the event.Results    The age-standardized incidence of MACVE in patients with IHD and COPD was 31.5 vs. 23.2 % in patients with IHD without concurrent COPD (p=0.025), primarily due to an increased frequency of repeated unscheduled MR (20.5 vs. 14.0 %, p=0.041), which was associated with earlier occurrence of adverse events (p<0.001). Repeated unscheduled MR was more frequently performed in patients with moderate COPD; the frequency of MR decreased with increasing severity of COPD, whereas the total incidence of cardiovascular death, myocardial infarction, and stroke was the highest in patients with severe and very severe COPD.Conclusion    The presence of concurrent COPD increases the relative risk of MACVE 1.36 times (95 % confidence interval: 1.05-1.75) and facilitates their earlier development. Repeated unscheduled MR makes the major contribution to the increase in the total risk (relative risk, 1.46; 95 % confidence interval: 1.03-2.06). The increase in severity of COPD is associated with the increase in total frequency of MACVE (p=0.005).

[Left ventricular global function index as a predictor of adverse cardiovascular events in patients with acute coronary syndrome].

Aim      To evaluate the prognostic significance of the left ventricular global function index (LV GFI) in patients with acute coronary syndrome (ACS) using echocardiography (EchoCG).Material and methods             The LV GFI is an index that integrates LV cavity volumes, stroke volume, and myocardial volume. This study included 2169 patients with ACS (1340 (61.8%) men) aged 64.1±12.6 years from two observational multicenter studies, ORACLE I and ORACLE II. 1800 (83 %) cases were associated with increased concentrations of myocardial injury markers, including 826 (38.1 %) cases of ST segment elevation myocardial infarction (MI). The observation was started on the 10th day of clinical condition stabilization and lasted for one year. EchoCG was performed with evaluation of LV GFI, which was calculated as a ratio of LV stroke volume to LV global volume. The LV global volume was calculated as a sum of mean LV cavity volume (LV end-diastolic volume + LV end-systolic volume / 2) and LV myocardial volume.Results The main outcome of the study was all-cause death (n=193); recurrent coronary complications (n=253) were analyzed separately. The only EchoCG parameter indicating an adverse outcome during the one-year follow-up was a LV GFI decrease to below 22.6 % with a sensitivity of 72 % and a specificity of 60% (area under the curve, AUC=0.63). A LV GFI <22.6 % was an independent predictor of all-cause death (p=0.019) along with age (p=0.0001), history of MI (p=0.034), and presence of heart failure (HF) (p=0.044), diabetes mellitus (p=0.012), and peripheral atherosclerosis (p=0.001). The LV GFI <22.6 %, (p=0.044), heart rate upon discharge from the hospital (p=0.050), history of MI (p=0.006), presence of HF (p=0.014), and peripheral atherosclerosis (p=0.001) were also independent predictors for recurrent coronary complications. Decreased LV GFI was associated with the risk of fatal outcomes independent of the LV ejection fraction at baseline.Conclusion      In patients with ACS, the left ventricular global function index is an independent predictor for all-cause death and recurrent coronary complications and may be used for risk stratification.

[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.

[Changes in the management of patients with acute coronary syndrome - have the disease outcomes changed?]

Aim        To analyze results of changing the management tactics in patients with acute coronary syndrome (ACS) in clinical practice from 2004 through 2018 expressed as improvement in prognosis.Material and methods        Results of two observational studies were analyzed: ORACLE I (2004-2007), which included 1193 patients with ACS (mean age, 61.1±11.69 years; men, 63.3 %) and ORACLE II (2014-2017), which included 1652 patients from 4 vascular centers (mean age, 64.61±12.67 years; men, 62.3 %).Results   Patients included into the ORACLE II study in 2014 were significantly older and the proportion of patients with diabetes mellitus was greater than in the ORACLE I study (14.7 and 22.6 %, respectively). After matching the groups by major clinical characteristics, it was found that introducing the invasive management tactics for ACS patients was associated with a reduced rate of all-cause death (from 8.2 to 6.1 % for one year), a tendency towards decreased number of coronary death cases (from 5.6 to 4.0 %), and a decrease in risk of recurrent coronary complications (from 17.4  to 7.7 %).Conclusion            Implementing the vascular program statistically significantly decreased the total death rate for at least one-year observation in comparable patient groups.

[3-years outcome of follow-up of patients with chronic obstructive pulmonary disease successfully treated by percutaneous coronary intervention due to acute coronary syndrome].

Aim To evaluate results of three-year follow-up in patients after acute coronary syndrome (ACS) associated with chronic obstructive pulmonary disease (COPD) and to identify predictors for delayed serious cardiovascular adverse (SCVAE) events.Material and methods This prospective cohort study included 119 patients with verified COPD who had ACS after a successful urgent percutaneous coronary intervention and were discharged from the hospital without in-hospital complications. Incidence of and time to SCVAE (cardiovascular death, myocardial infarction, stroke, repeated unscheduled myocardial revascularization) were recorded. SCVAE predictors were identified with the Cox regression by stepwise inclusion of variables into the model.Results SCVAE occurred in 33.6 % of ACS patients with COPD. The high rate of repeated myocardial revascularization mostly contributed to the development of delayed SCVAEs (19.3 % of patients). Independent predictors of SCVAE included the total number of stenoses in major coronary artery branches; ankle-brachial index; glomerular filtration rate calculated with the CKD-EPI equation; frequent COPD exacerbations; functional residual capacity of the lungs; and 6-min walk distance.Conclusion New independent predictors of SCVAE were identified in COPD patients after ACS with percutaneous coronary intervention and stenting, including distance in the 6-min walk test, frequent COPD exacerbations, and functional residual volume of the lungs as an index of pulmonary hyperinflation.

[Prediction of long-term adverse cardiovascular events after percutaneous coronary interventions in patients with coronary artery disease and concomitant chronic obstructive pulmonary disease].

Aim To identify independent predictors for long-term serious adverse cardiovascular events following percutaneous coronary interventions (PCI) in patients with a combination of ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD) and to develop a prognostic mathematical model.Materials and methods Design: a prospective cohort study. The study included 254 patients with IHD associated with COPD after PCI (in 119 patients, PCI was performed for acute coronary syndrome and in 135 patients, PCI was elective). Follow-up duration was up to 36 months. Composite endpoint included cardiovascular death, myocardial infarction, stroke or repeated, unscheduled myocardial revascularization. Cox regression with stepwise inclusion of variables was used for identification of predictors for the composite endpoint.Results The following independent predictors of serious adverse cardiovascular events were identified: number of stenoses in major coronary artery branches, ankle-brachial index. glomerular filtration rate, age, distance in 6-min walk test, COPD phenotype with frequent exacerbations (FE), and functional residual capacity (FRC) of lungs. The mathematical model based on the Cox regression for prediction of serious adverse cardiovascular events had a 75% sensitivity and a 81% specificity.Conclusion Incidence of long-term serious adverse cardiovascular events in patients with a combination of IHD and COPD after PCI depends not only on traditional cardiovascular risk factors but also on characteristics of COPD itself, such as the FE phenotype and the FRC indicative of lung hyperinflation. The proposed mathematical model based on the Cox regression can be used for evaluating the odds for adverse cardiovascular events after PCI in patients with a combination of IHD and COPD.

[Specific Features of the Course of Acute Coronary Syndrome in Patients with Newly Developed Atrial Fibrillation in Clinical Practice According to the Data of the Register of Acute Coronary Syndrome].

AIM: to elucidate risk factors of development of atrial fibrillation (AF) in patients with acute coronary syndrome (ACS), and to assess of patient's adherence to oral anticoagulant therapy (OAT) during 12 months after ACS episode according to the data of the Total ACS Registry for the Krasnodar Territory. MATERIALS AND METHODS: In this retrospective analysis we used Registry data on patients with ACS and concomitant AF, consecutively admitted to cardiological departments of the S.V. Ochapovsky Territorial Clinical Hospital from 20/11/2015 to 20/02/18. Number of patients in the analyzed group was 201 (52 with AF which first appeared in connection with the index ACS). Survivors after hospital discharge were contacted by telephone and at planned visits. The analysis included assessment of rates of the following outcomes: inhospital death, hemorrhagic and thromboembolic complications, prognostic efficacy of the CRISADE and HAS BLED scores, and expediency of prescription to patients with ACS and concomitant first AF episode of prolonged OAT after hospital discharge. RESULTS: Demographic and anamnestic data of patients with the first AF attack at the background of ACS were like those of patients with other types of AF. This group of patients was characterized by more severe course of the disease, but this produced no impact on inhospital mortality and rate of complications, as well as on mortality for 12 months after hospital discharge. CONCLUSION: The results of this analysis are important for understanding distinctive characteristics of patients with AF first developed during ACS.

[Lipid spectrum and function of kidneys before and after liver transplantation].

BACKGROUND: In patients after liver transplantation cardiovascular complications is the third main reason of death afer allograf failure and infections. The most important factors in the development of cardiovascular diseases are dyslipidemia and impaired renal function. The aim of the study was to investigate the lipid spectrum and renal function in liver recipients in real clinical practice and the correspondence of their correction to current clinical recommendations for the diagnosis and treatment of dyslipidemia and chronic kidney disease (CKD). METHODS: A retrospective analysis of lipid spectrum and renal function in patients who underwent OLT in Research Institute - Regional Clinical Hospital №1, Krasnodar was performed. The level of creatinine, GFR and lipid spectrum was studied before and 36 months after liver transplantation. The GFR was calculated using the formula CKD­EPI (Chronic Kidney Disease Epidemiology Collaboration). Statistical analysis of the study results was made using the program Statistica 10. RESULTS: Liver recipients have a significantly higher total cholesterol by 31.0% (p<0.01) in comparison with the baseline before surgery. Total cholesterol was increased in 13.7% (p<0.01), triglycerides in 12.3% (p<0.01) before transplantation. Tree years after transplantation, the increasion in cholesterol was registered in 42.6% (p<0.01) and triglycerides in 37.9% (p <0.01), respectively. 3 years after transplantation reduction of GFR was observed in comparison with the baseline by 22.6% (p=0.00006). Verification of chronic kidney disease and statin administration in patients were carried out in some cases. The levels of total cholesterol and triglycerides had a reliable inverse correlation with GFR (r = ­0.42; p<0.01 and r = ­0.36; p<0.05). CONCLUSIONS: In the long­term postoperative period there was an impaired lipid metabolism and decreased level of GFR. Dyslipidemia was closely related to the progression of renal dysfunction in liver recipients, an inverse correlation was established between the glomerular filtration rate and the increasion in cholesterol and triglyceride levels. It is necessary to increase the attention of physicians with regard to timely correction of lipid metabolism disorders and detection of initial manifestations of renal dysfunction.

[The Phenotype of Chronic Obstructive Pulmonary Disease With Frequent Exacerbations in the Aspect of Long-term Percutaneous Coronary Intervention Results].

OBJECTIVE: To evaluate the results of percutaneous coronary interventions (PCI) in patients with coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD), depending on the frequency of exacerbations of COPD. MATERIALS AND METHODS: We enrolled in this prospective study 103 patients with CHD and COPD who underwent PCI (n=103) including 25 who satisfied criteria of COPD phenotype with frequent exacerbations (main group). Analysis included comparison of rates and times to major adverse cardiac events (MACE - myocardial infarction, stroke, cardiac death, repeat revascularization) in the main group and other patients. Clinical and functional features of patients with major adverse cardiac events were also analyzed. RESULTS: Study groups did not differ significantly on demographic characteristics and the presence of comorbidity. MACE frequency was almost 2 times higher in the main group (relative risk 1.87; 95% confidence interval (CI) 1.1-3.3). There was a tendency to higher rate of MACE among patients with history of more or equal 1 COPD exacerbations in a year (40% vs. 24%, p=0.09). The following clinical and functional characteristics of COPD, were associated with MACE in remote period after PCI: frequency of exacerbations, results of the COPD Assessment Test, exercise capacity, forced expiratory volume in 1 sec. Conclusion/ COPD phenotype with frequent exacerbations in patients with CHD undergoing PCI is associated with increased risk and earlier occurrence of MACE.

[Myocardial Revascularization in Patients With Chronic Ischemic Heart Disease Combined With Chronic Obstructive Pulmonary Disease].

Currently enough data has been accumulated to consider chronic obstructive pulmonary disease (COPD) as one of important factors of poor prognosis in patients with coronary artery disease, possibly producing an impact on perioperative risk during coronary artery bypass grafting surgery and percutaneous coronary interventions, as well as on long-term outcomes of these procedures. In this review we have analyzed studies which attempted to assess COPD as a factor that can affect outcomes of myocardial revascularization.

[Changing Clinical Presentation of Acute Coronary Syndrome in Patients With Chronic Obstructive Pulmonary Disease].

OBJECTIVE: to determine clinical features of acute coronary syndrome (ACS) in patients with chronic obstructive pulmonary disease (COPD). METHODS: We included into this study 272 patients with ACS, 110 with and 162 without concomitant COPD. In both groups we registered prevalence of atypical forms of ACS debut, severity of acute heart failure (Killip class), time from symptoms onset prior to percutaneous coronary intervention (PCI), as well as the prevalence of cardiac arrhythmias. RESULTS: Demographic characteristics and presence.

[Detection of Determinants of Functional Aortic Regurgitation in Patients With Ascending Aorta Aneurism by Transesophagea1 Echocardioscopy].

We used transesophageal echocardioscopy for the study of effects of linear parameters of the aortic root and characteristics of its subvalvular space (area of subvalvular space of the aortic root during diastole and aortic cusps coaptation height) on severity of aortic regurgitation in patients with aneurism of ascending aorta and anatomically unchanged aortic valve (AV), i.e. so-called functional aortic regurgitation (FAR). We found that appearance of FAR was associated with coefficient of disproportion sinotubular ridge/fibrous annulus of AV > 1.67, aortic cusps coaptation height > 0.47 cm and area of subvalvular space of the aortic root >0.49 cm2. Respective values > 2.23, > 1.07 cm, 0.49 cm2 evidenced for the presence of pronounced FAR.

[Chronic Obstructive Pulmonary Disease as a Factor of Unfavorable Cardiovascular Prognosis After Percutaneous Coronary Interventions in Ischemic Heart Disease].

AIM: to elucidate effect of concomitant chronic obstructive pulmonary disease (COPD) on remote results of percutaneous coronary intervention (PCI) with stent implantation in patients with ischemic heart disease (IHD). MATERIAL AND METHOD: We analyzed data of long term follow-up of 346 IHD patients after PCI with stenting. Groups of patients with and without COPD had comparable baseline clinical and functional characteristics. During follow-up we registered cardiovascular events (cardiovascular death, myocardial infarction, stroke, revascularization), as well as time to first event with the construction of Kaplan-Meier curves. RESULTS: Difference in relative frequency of occurrence of studied events between groups was not significant (24 and 17% among patients with and without COPD respectively, p=0.13), but in patients with COPD events occurred significantly earlier (p=0.02). Patients with adverse cardiovascular events during follow-up at baseline had lower exercise tolerance and glomerular filtration rate, more often had diabetes.

[Detection of Determinants of Functional Aortic Regurgitation in Patients With Ascending Aorta Aneurism by Transesophageal Echocardioscopy].

We used transesophageal echocardioscopy for the study of effects of linear parameters of the aortic root and characteristics of its subvalvular space (area of subvalvular space of the aortic root during diastole and aortic cusps coaptation height) on severity of aortic regurgitation in patients with aneurism of ascending aorta and anatomically unchanged aortic valve (AV), i.e. so-called functional aortic regurgitation (FAR). We found that appearance of FAR was associated with coefficient of disproportion sinotubular ridge/fibrous annulus of AV>1.67, aortic cusps coaptation height >0.47 cm and area of subvalvular space of the aortic root >0.49 cm2. Respective values >2.23, >1.07 cm, 0.49 cm2 evidenced for the presence of pronounced FAR.

[Postoperative complications after orthotopic heart transplantation].

We analysed postoperative complications in 106 patients after orthotopic heart transplantation based on the results of prospective observations during 2 year follow-up. Survival was estimated at 83% (88 patients). Deaths were caused by pyoseptic complications, pulmonary thromboembolism, acute pancreatitis, cardiac arrhythmia or transplant rejection due to non-compliance with the immunotherapeutic regime. The most frequent causes of deaths were pneumonia (28.3%), transplant rejection (11.3%), steroid-induced diabetes (14.6%). It is concluded that heart transplantation should be followed by thorough observation of the patients based at a specialized multi-field clinic to ensure continuous treatment and reduce lethality. Risk factors of unfavourable prognosis of heart transplantation are identified.

[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.

[Three years experience of catheter treatment of patients with acute coronary syndrome in conditions of 24-hour work of endovascular service].

In this work we have summarized 3-years experience of the treatment of acute coronary syndrome with the use of endovascular methods and presented organizational basis allowing to realize 24-hour work of the endovascular service, and algorithm of examination and treatment of patients admitted with diagnosis of acute coronary syndrome. During the analyzed period invasive interventions were carried out in 1417 patients (transluminal angioplasty - in 93, angioplasty with stenting - in 1356 patients) with mean door to balloon time 37.7 min. For stenting we used 925 standard metal stents and 584 drug eluting stents. Coronary artery bypass surgery was performed in 150 patients. Severe complications during hospital stay developed in 3% of patients. Fifteen patients died, 14 of them were admitted in a state of cardiogenic shock. Repeat coronary angiography in remote period was fulfilled in 170 patients with recurrence of angina. Restenoses were found in 31.2% of these patients, predominantly in those with implanted standard metal stents.

[The baroreceptor reflex as a predictor of crises in arterial hypertension]. / Sostoianie baroretseptornogo refleksa kak prediktor krizovogo techeniia arterial'noi gipertonii.

The sensitivity of baroreceptor reflex was determined by the "neck chamber" method at a pressure of 40 mm Hg in patients with mild, moderate and malignant arterial hypertension (AH). A 24-hour blood monitoring was performed in patients with mild and moderate AH. There was a negative correlation between the lowering values in blood pressure on baroreceptor stimulation and the incidence of hypertensive crises in all the groups. There was also a negative correlation between the baroreceptor sensitivity and the daily blood pressure variations in patients with moderate AH. The findings suggest that a decrease in baroreceptor sensitivity might be a predictor of the critical course of AH.

[Effects of surgical treatment on hypertrophy of the myocardium of the left ventricle in patients with symptomatic arterial hypertension]. / Vliianie operativnogo lecheniia na gipertrofiiu miokarda levogo zheludochka u bol'nykh s simptomaticheskimi arterial'nymi gipertoniiami.

A total of 50 patients with arterial hypertension were examined. Group 1 included 28 patients with renovascular hypertension, 18 of them had unilateral renal artery stenosis, the remaining 10 had bilateral renal artery stenosis. Group 2 consisted of 16 patients with primary aldosteronism. Group 3 comprised 6 patients with pheochromocytoma. The examination was made with echocardiograph. Changes in left ventricular myocardial mass (LVMM) were studied 1 and 6 months after surgical intervention. The maximum hypertrophy was observed in the patients with primary aldosteronism, no changes occurred in any of the groups examined 1 month after surgical management. The LVMM was found to be significantly diminished by 13% in the patients with renovascular hypertension and by 23% in patients with adrenal tumors (pheochromocytoma, aldosteroma).