Editorial on the article «Natriuretic Peptide Concentrations and Echocardiography Findings in Patients with Micro-atrial Fibrillation¼.

In relation with the published article "Natriuretic Peptide Concentrations and Echocardiography Findings in Patients with Micro-atrial Fibrillation", we have issued a comment. The authors of the article addressed a widely discussed topic of "Short episodes of fast arrhythmias initially detected in records on implantable devices". Further, these episodes are studied already by Holter monitoring of different durations with assessment of their clinical significance. This is the subject of the cited article and our comment.

[Пятилетнее исследование влияния кардиомониторинга на общую выживаемость Ð±Ð¾Ð»ÑŒÐ½Ñ‹Ñ Ñ Ñ€Ð¾Ð½Ð¸Ñ‡ÐµÑÐºÐ¸Ð¼ лимфолейкозом, Ð¿Ð¾Ð»ÑƒÑ‡Ð°ÑŽÑ‰Ð¸Ñ Ñ‚Ð°Ñ€Ð³ÐµÑ‚Ð½ÑƒÑŽ терапию ибрутинибом].

Aim      To evaluate the effect of cardiac monitoring on overall survival of patients with chronic lymphoid leukosis (CLL) on targeted therapy with ibrutinib.Material and methods  Survival of oncological patients depends not only on the efficacy of the antitumor therapy. Cardiovascular comorbidities and emerging cardiotoxicity of the antitumor treatment can considerably impair the quality and duration of patients' life. The problem of the need for regular cardiological monitoring of oncological patients remains unsolved. A prospective 5-year study was performed that included cardiological monitoring of patients with CLL on chronic targeted therapy with ibrutinib, the side effects of which include atrial fibrillation (AF) and arterial hypertension (AH). The study included 217 patients aged 66.0 [32.0; 910.] years; 144 of them were men aged 66.0 [32.0; 91.0] years and 83 were women aged 65.0 [39.0; 83.0] years. Electrocardiography and echocardiography, evaluation of comorbidity with the Charlson's index, and evaluation of frailty with the Geriatric 8 questionnaire and the Groningen Frailty Index were performed repeatedly for all patients. In the active cardiac monitoring group (n=89), besides the standard evaluation, active medical monitoring of symptoms and general well-being, blood pressure (BP) and pulse rate, monitoring of cardioprotective drug intake and correction, if necessary, and calling patients for examination and additional evaluation were performed every week. The remaining 128 patients were evaluated repeatedly but did not maintain the remote monitoring with messengers; they constituted a standard follow-up group.Results This was a study of overall survival of patients with CLL on targeted therapy with ibrutinib depending on the cardiac monitoring program. The age of patients did not differ in the active cardiac monitoring group and the standard follow-up group (66.0 [60.0; 70.0] and 66.0 [59.0; 74.0] years, respectively). The active cardiac monitoring group contained somewhat more men than the standard follow-up group (68.8 and 53.9 %, respectively; р=0.026). At baseline, the groups did not differ in the number of pretreatment lines, frailty test results (Geriatric 8 questionnaire, Groningen Frailty Index), comorbidity (Charlson's index), and echocardiographic data. The active cardiac monitoring group contained more patients with AH (р<0.0001), with AF (р<0.0001), patients receiving anticoagulants (р<0.0001), and a comparable number of patients with ischemic heart disease. In the active cardiac monitoring group, 70 (90.9%) of 77 patients with CLL and AH achieved goal BP whereas in the standard follow-up group, 26 (39.9 %) of 66 (р<0.0001) patients achieved the BP goal, regardless of whether their elevated BP developed before or during the ibrutinib treatment. This group contained significantly more patients who required cardiac surgical intervention (coronary stenting, pacemaker implantation), 12 vs. 0 in the standard follow-up group (р=0.0004). The overall 5-year survival was significantly higher for patients of the active cardiac monitoring group, both for men (р<0.0001) and women (р<0.0001) with CLL, including patients older than 70 years (р=0.0004), CLL patients with a median pretreatment line number of 1 (р<0.0001), patients with a median chemotherapy line number of 4 (р<0.0001), and patients with genetic abnormalities (р=0.004) pretreated with fludarabine and/or anthracyclines (р<0.0001). The Cox regression analysis showed that the strongest predictor of survival was the achievement of stable goal BP in CLL patients with AH during the continuous cardiac monitoring. Despite more pronounced cardiac comorbidity, CLL patients on the active cardiac monitoring group showed a longer survival than patients on the standard follow-up. Thus, mean survival time of deceased CLL patients who had been on the cardiac monitoring was 36.1 months vs. 17.5 months (р<0.0001) for patients who had been on the standard follow-up.Conclusion      The study has demonstrated the prognostic significance of continuous participation of a cardiologist in managing onco-hematological patients. CLL patients on the active cardiac monitoring, the regular pattern of which was provided by the remote control, had a significantly higher overall survival compared to patients who visited a cardiologist periodically. A significant predomination of patients with CLL and AH who achieved stable goal BP, continuous monitoring of anticoagulant dosing in patients with AF in that group, and early detection and correction of cardiovascular complications can explain the highly significant difference in the 5-year survival between CLL patients on chronic targeted ibrutinib treatment with different cardiac monitoring programs (р<0.0001). The active cardiac monitoring with remote control allows achievement of a higher 5-year overall survival of CLL patients receiving ibrutinib (p<0.0001).

[Heart reHeart remodeling in patients with severe systolic dysfunction due tocancer chemotherapymodeling in patients with severe systolic dysfunction due tocancer chemotherapy.]

Objective Comparative analysis of structural and functional specific features of the heart in patients with toxic cardiomyopathy (TCMP) with a low left ventricular ejection fraction (LVEF) and severe, chronic heart failure (CHF) and in patients with idiopathic dilated cardiomyopathy (DCMP) and similar LVEF and CHF severity.Materials and Methods This observational, single-site study included 15 patients with TCMP (12 of them received treatment including anthracycline antibiotics and 3 patients received targeted therapies) and 26 patients with idiopathic DCMP. Data of echocardiography were compared for patients with TCMP and DCMP with comparably low LVEF of <40 %.Results In patients with severe heart damage associated with antitumor therapy with low LVEF, volumetric and linear indexes of left and right ventricles and the left atrium (left atrial volume index (LAVI), 33.7 (21.5-36.9) ml / m2; right ventricular end-diastolic dimension (RVDd), 2.49 (1.77-3.53) cm; and end-diastolic volume index (EDVI), 78.0 (58.7-90.0) ml / m2) were considerably less than in the DCMP group (LAVI, 67.1 (51.1-85.0) ml / m2; RVDd, 4.05 (3.6-4.4) cm; and EDVI, 117.85 (100.6-138.5) ml / m2, p<0.0001). Furthermore, LV wall thickness and pulmonary artery systolic pressure did not differ in these groups. Both in men and women with TCMP, LAVI and EDVI were significantly less than in men and women with DCMP.Conclusion The study showed significant differences in parameters of cardiac remodeling. In TCMP patients as distinct from DCMP patients, despite a pronounced decrease in LVEF, LV dilatation was absent or LV volumetric parameters were moderately increased with a more severe somatic status.

Heart valve injury due to radiation therapy.

RELEVANCE: Radiation therapy (RT) plays an important role in oncology, improving the immediate and long-term results of treatment of a number of tumors. One of the most significant complications of RT are lesions of the heart valves. OBJECTIVE: To study the variants of valve damage that occur in patients who received radiation therapy for cancer. PATIENTS AND METHODS: A group of patients who, during the period from 1978 to 2002, underwent chemo-radiation therapy (CRT) for Hodgkin's lymphoma (LH) of 2-4 stages with damage to the intrathoracic lymph nodes: 71 patients, 60 of whom did not go to the cardiologist and were invited to be examined, 11 were hospitalized due to clinically significant cardiovascular pathology (CHF, myocardial infarction, angina pectoris, valvular defect, AV block). The study methods included: standard clinical and laboratory examination, spirometry, 24­hour ECG monitoring, echocardiography, in some patients single-photon myocardial emission tomoscintigraphy (SPECT), and CT scan of the chest organs. In 60 patients, a stress test on an ECG-controlled treadmill was performed, in 18 patients - a maximum stress test on a treadmill with a gas analysis - ergospirometry. RESULTS AND DISCUSSION: Valve pathology was detected in 49.3 % of cases, most often (in 46.5 %) mitral regurgitation (MR) occurred, primarily due to MR of the 1 st degree, which had no clinical significance. Pathology of the aortic valve (12.7 % of patients) was represented mainly by mild regurgitation (11.3 %). Aortic stenosis was diagnosed in 4.2 % of patients. In the studied cohort of patients, predominantly non-severe valve lesions were detected. In addition, examples of patients with clinically significant valve valvular lesions are presented.

[Significance of comorbidity for patients with chronic lymphocytic leukemia].

BACKGROUND: Chronic lymphocytic leukemia (CLL) remains an uncurable disease, in which the age, number and severity of comorbidities primarily determine the choice of therapeutic tactics and objectives. AIM: To evaluate actual comorbidity and polymorbidity in patients with CLL and a possible relationship between the diseases and comorbidities that are considered concurrent and side effects of the administered treatment. MATERIALS AND METHODS: The study consisted of two parts. In a retrospective study, we analyzed records of patients with CLL from the Registry for Diagnostics and Treatment of Lymphoproliferative Diseases. In addition, we thoroughly evaluated and prospectively followed up 124 patients in the course of their preparation to a new stage of CLL tratement. RESULTS: Examining data from the Russian Registry for Diagnostics and Treatment of Lymphoproliferative Diseases (n=1361) showed that in Russia, the age of patients with newly diagnosed CLL has increased in the recent decade with the increase in life span, which might change the comorbidity structure. Comparing retrospective and our own data (n=124) showed that diagnoses of concurrent diseases are often recorded formally (p3 suggested a poor prognosis for patients with CLL. CONCLUSION: Diagnosis and treatment of comorbidities in patients with CLL require participation of different medical specialists working in a close contact with oncohematologists.

[Management of patients with isolated aortic stenosis considering negative prognostic factors].

BACKGROUND: Aortic stenosis (AS) is the most common valve defect in developed countries; its prevalence increases with age of the population. The most frequent cause for isolated AS in adults is calcification of normal tricuspid or congenital bicuspid aortic valve (AV). The only effective treatment of AS is aortic valve replacement (AVR). Major negative prognostic factors include low LV ejection fraction (EF), age older than 70, female gender, and comorbidities such as renal dysfunction, chronic obstructive pulmonary disease, and neural disorders. AIM: To study negative prognostic factors influencing outcomes of treatment for AS and to determine possibilities for managing AS patients taking into account these factors. MATERIALS AND METHODS: 120 medical records of patients who had undergone AVR for isolated AS (76 women and 44 men aged 45 to 81) were studied retrospectively, and 50 patients were examined in a late post-AV period (26 women aged 67.5 (65.0-72.0) at the time of surgery, 24 men aged 63.0 (57.0-68.0) at the time of surgery), and 84 unoperated patients (51 women and 33 men). RESULTS: Perioperative death rate was 8.76 %, 11 of 120 patients, 3 men (6.8 % of operated men) and 8 women (10.5 % of all operated women). The deceased patients aged 70 or older whereas perioperative death rate of patients younger than 70 was zero (Pχ 2 =0.004). Despite a relatively high perioperative risk, late survival of patients older than 70 who had undergone AVR was substantially and statistically significantly higher than that of unoperated AS patients. In elderly patients who died during the perioperative period of AVR, the history of valve defect was longer, and a part of the patients who did not survive AVR could have been operated at age younger than 70. Unoperated AS patients with a small LV cavity, severe LV hypertrophy, and LV EF >70 % were suggested to be isolated into a special group of risk with a special strategy for cardiosurgical treatment.

[Pulmonary arterial hypertension and chronic heart failure as dasatinib cardiotoxicity. A case report].

Modern treatment of patients with oncohematological diseases has allowed to achieve remission or even convalescence in many cases. One of ambitious aims put forward by the hematological society is 100% survival and preservation of quality of life in patients with chronic myeloid leukemia (CML). This hope is related with the emergence of targeted therapy for CML. The second-generation tyrosine kinase inhibitor, dasatinib, which is used for treatment of CML, can occasionally induce severe pulmonary hypertension (PH). We presented here a case report of such cardiotoxicity, which was evident as PH and heart failure in a young female patient with CML treated with dasatinib. Information from published reports about this type of cardiotoxicity is provided. At present time, dasatinib is beginning to be extensively used also in other oncological diseases. For this reason, cardiologists and physicians should be aware of this cardiotoxicity, which can cause heart failure in dasatinib-treated patients.

[Possibilities of modern echocardiographic technologies in the early diagnosis of the cardiotoxic effect of chemotherapy drugs anthracycline series in cancer patients].

Chronic heart failure following chemotherapy for cancer is a relevant issue of an adverse cardiovascular prognosis and premature death in cancer patients. This category of patients requires thorough and chronic monitoring of the cardiovascular system, prevention and treatment of cardiovascular complications of chemotherapy, such as IHD, systolic or diastolic myocardial dysfunction, arterial or pulmonary hypertension, pulmonary thromboembolism, pericarditis, stroke, and peripheral vascular disease. However, many aspects of this important interdisciplinary issue presently remain understudied. For instance, it is still impossible to predict long-term consequences of chemotherapy for cancer and development of the associated cardiovascular complications listed above. Baseline evaluation of the risk for cardiovascular complications is a major component in management of such patients. High-risk patients need an individual, detailed schedule of cardiovascular treatment throughout and after the course of chemotherapy. Furthermore, early detection of subclinical myocardial dysfunction is critical for prevention of the most threatening cardiovascular complications of chemotherapy, CHF. Detecting impaired LV EF following chemotherapy is, unfortunately, only a late predictor of irreversible changes, such as toxic cardiomyopathy and clinically pronounced, rapidly progressing CHF. Markers of myocardial injury, high-sensitivity troponins and natriuretic peptides, in combination with up-to-date EchoCG technologies have been recently used. Their use, for instance, for evaluation of LV myocardial global longitudinal strain to detect early, reversible changes in structure and mechanics of the myocardium is promising for ultimate improvement of prediction for such patients.