Terapevticheskii arkhiv

The editorial discusses a wide range of relationships between arterial hypertension, lipid metabolism disorders, and atherosclerosis. The history of the issue and basic data on the epidemiology of these diseases are highlighted in detail. The features of the pathogenesis of atherosclerosis in combination with arterial hypertension are presented. Modern approaches to the choice of biochemical and instrumental methods of examination of patients with a combination of pathology, as well as clinical features, are discussed. The most important part of the article is the discussion about modern approaches to non-drug and drug treatment, taking into account current recommendations.

Small airways disease (SAD) in bronchial asthma (BA) has been characterized in detail, yet it is rarely assessed in routine care and is not reflected in current stepwise treatment algorithms. In the ATLANTIS (Assessment of Small Airways Involvement in Asthma) study, signs of SAD were detectable in 91% of patients with BA, and an oscillometry-based composite score predicted asthma control and exacerbation risk independently of forced expiratory volume in 1 second. The aim of publishing the resolution of the Expert Council was to summarize the evidence on the clinical relevance of SAD, to define the diagnostic methods available in Russian health care, and to clarify the place of extrafine inhaled formulations within the treatment algorithm. SAD should be regarded as a treatable trait of asthma and assessed routinely in patients who do not achieve control. Impulse oscillometry with assessment of R5–R20 (resistance at 5 Hz – 20 Hz), area of reactance (AX) and X5 (reactance at 5 Hz) was endorsed as the method of choice; where IOS is unavailable, FEF_25–75 may be used provided forced vital capacity is normal. Extrafine inhaled corticosteroids (ICS) are associated with a higher likelihood of achieving control (odds ratio 1.34; 95% confidence interval 1.22–1.46) and a lower exacerbation rate (rate ratio 0.84, 95% confidence interval 0.73–0.97) at a mean prescribed ICS dose 170 μg/day lower. When control is not achieved on ICS/LABA (long-acting β₂-agonist) or ICS/LABA/LAMA (long-acting muscarinic antagonist), switching to an extrafine formulation within the same treatment step should be considered before the ICS dose is increased.

Background. Despite anticoagulant therapy (AT), the annual incidence of ischemic stroke (IS) remains 2.5–4.5% per year. The factors determining the residual risk are currently being actively studied. The prognosis of elderly patients is influenced by the frailty syndromes.

Aim. Based on prospective follow-up data, the frequency and predictors of IS / transient ischemic attack (TIA) / systemic embolism (SE) were determined in patients with atrial fibrillation over 60 years on AT.

Materials and methods. 600 patients from the REGATTA-2 registry were included. We used the questionnaire „Age is not a hindrance“ to study frailty.

Results. Frequency of the combined endpoint in all cohort was 3.7 per 100 patient-years. According to the Cox proportional hazards model, independent predictors of the development of IS/TIA/SE in patients receiving AT were: female gender [Hazard ratio (HR) 1.6], arterial hypertension (HR 6.1), history of IS/TIA/SE (HR 1.6), anemia (HR 1.9), failure to achieve target blood pressure levels (HR 2.2) and cholesterol (HR 2.6), cognitive impairment (HR 2.3), emotional disorders (HR 1.6) and severe physical activity restrictions (HR 2.5).

Conclusion. Currently, it is advisable to introduce geriatric tools into the system of stratification of residual risk in elderly and senile atrial fibrillation patients.

Aim. To compare myocardial deformation indicators between the left (LA) and right atria (RA) using speckle tracking echocardiography in adult patients with septal defects and to identify parameters associated with the atrial fibrillation (AF).

Materials and methods. A prospective study conducted from 2022 to 2025 included 120 patients with congenital heart disease and left-to-right blood shunting (mean age 51.0±13.1 years). The congenital heart defects in the cohort included atrial septal defect in 82.5% (n=99), partial anomalous pulmonary vein drainage with atrial septal defect in 11.7% (n=14), and partial atrioventricular canal in 5.8% (n=7); in all cases, a significant arteriovenous shunt was observed. Paroxysmal AF was diagnosed in 29.8% of patients.

Results. Notable RA dilation was observed with indexed RA volume of 49.9±18 mL/m², while the indexed LA volume was borderline at 32.6±12.4 mL/m², showing a significant difference between the two (p<0.001). Additionally, deformation parameters during the contraction phase also differed significantly (p<0.002). Moderate to strong correlations were established between the volumetric and deformation parameters of both chambers. The independent predictors of AF, identified through multivariate analysis, included the left atrial volume index (LAVI) (odds ratio 1.098, 95% confidence interval 1.029–1.171; p=0.005) and the estimated right ventricular systolic pressure (eRVSP) (odds ratio 1.080, 95% confidence interval 1.004–1.163; p=0.040).

Conclusion. Morphofunctional changes associated with septal defects are characteristic of both RA and LA. LAVI and eRVSP are independent predictors of AF development, highlighting the importance of a comprehensive assessment of both the right and left heart chambers.

Aim. To identify clinical and laboratory predictors of gastrointestinal bleeding in patients with coronary artery disease (CAD) receiving antiplatelet therapy.

Materials and methods. A single-center cohort study was conducted, including 161 patients with CAD receiving antiplatelet therapy. The study group consisted of 55 patients with gastrointestinal bleeding (GIB), and the control group included 106 patients without GIB during the entire follow-up period. Demographic data, risk factors (smoking, diabetes mellitus, arterial hypertension), laboratory parameters [hemoglobin, creatinine, eGFR (by CKD-EPI formula), glucose, H. pylori status], and therapy data were collected retrospectively. Prospective follow-up (for 6 months) assessed erosive and ulcerative changes by esophagogastroduodenoscopy and the occurrence of GIB. Independent predictors were identified using multivariable logistic regression analysis.

Results. The study included 161 patients with an established diagnosis of CAD receiving antiplatelet therapy. GIB was recorded in 55 (34.2%) patients. According to multivariable logistic regression analysis, independent predictors of GIB were: a history of duodenal ulcer (OR 6.57; p=0.005), smoking (OR 3.70; p=0.001), presence of pulmonary hypertension (OR 3.59; p=0.002), H. pylori infection (OR 3.41; p<0.001), as well as elevated glucose levels (OR 1.28 per 1 mmol/L; p<0.001) and creatinine levels (OR 1.02 per 1 μmol/L; p<0.001).

Conclusion. The identified predictors of GIB, including gastroenterological (duodenal ulcer history, H. pylori infection), behavioral factors (smoking), and comorbid conditions (hyperglycemia, elevated creatinine levels), can be used for risk stratification and timely effective prevention of GIB in patients with CAD receiving antiplatelet therapy.

Pulmonary arterial hypertension (PAH) is a rare precapillary vascular lesion characterized by progressive vasoproliferative remodeling of the microcirculatory bed, increased vascular resistance, and decompensation of the right ventricle. Despite the development of modern approaches to diagnosis and treatment, global and national epidemiological registries indicate a steady increase in the prevalence of the disease, which has an unfavorable prognosis. The fundamental problem in the pathogenesis of PAH is its prolonged latent course: obliteration of the pulmonary arterioles develops gradually, and the appearance of clinical manifestations of the disease correlates with already irreversible structural changes. A natural consequence of the subclinical onset is a diagnostic delay (on average 2–3 years from the onset of the first complaints), which is recognized as an independent predictor of an poor outcome. This review is dedicated to the analysis of the evolution of approaches to the treatment of PAH over the past two decades. The historical era of stepwise monotherapy, which provided purely symptomatic control, has been replaced by the concept of actively influencing three classic pathogenetic signaling pathways: the endothelin pathway (endothelin receptor antagonists), the nitric oxide pathway (type 5 phosphodiesterase inhibitors and soluble guanylate cyclase stimulators), and the prostacyclin cascade. The review systematizes data from modern meta-analyses and randomized clinical trials that convincingly demonstrate the superiority of initial dual and early sequential three-component therapy. Special attention is paid to the analysis of the evidence base for the non-selective oral agonist of IP receptors, selexipag. Based on the results of the landmark phase III GRIPHON study and long-term cohort observations by V. McLaughlin et al. lasting up to 10 years, the high clinical efficacy of including selexipag in combination therapy regimens has been confirmed. It has been proven that timely pharmacological modulation of the prostacyclin pathway ensures long-term control over disease progression, significantly reduces the frequency of hospitalizations, and improves survival. Thus, the prescription of multicomponent therapy in patients with PAH becomes a fundamental standard that modifies the natural course of the disease and significantly improves the prognosis.

The article describes the origins of the Siberian Therapeutic School. It highlights the contributions to its formation by professors of the medical faculty of Tomsk Imperial University (from 1930 – Tomsk Medical Institute) – A.P. Korkunov, M.G. Kurlov, P.A. Lomovitskiy, and D.D. Yablokov. Students of M.G. Kurlov and D.D. Yablokov successfully headed therapeutic departments in newly established medical Universities, which allows them to be considered the founders of the therapeutic school, having made the most significant contribution to the establishment of internal medicine clinics in Siberia.