Vol 92, No 1 (2020)


The epidemiological situation as a factor determining the strategy for reducing mortality in the Russian Federation

Boytsov S.A., Shalnova S.A., Deev A.D.


Chronic non - communicable diseases, mainly cardiovascular diseases, are the leading cause of death worldwide, including in the Russian Federation (RF). The article analyzes the negative and positive trends of the most relevant risk factors for cardiovascular diseases for the period from 2013 to 2017, and also provides a strategy for reducing mortality in the Russian Federation for the period up to 2024 based on data from an epidemiological analysis.
Terapevticheskii arkhiv. 2020;92(1):4-9
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Impact of endothelial dysfunction on the course of acute ST-elevation myocardial infarction and its correction by remote ischemic preconditioning

Manchurov V.N., Lebedeva A.M., Ryazankina N.B., Vasilieva E.Y., Shpektor A.V.


Aim of the study - to assess the effect of remote ischemic preconditioning (RIPC) on the incidence of endothelial dysfunction (ED) and its impact on hospital prognosis in patients with ST segment elevation acute myocardial infarction (STEMI). Materials and methods. We conducted a single - centre, open - label prospective study that included 173 patients with STEMI who underwent primary percutaneous coronary intervention within the first 24 hours of the symptoms onset. Before the PCI, patients were randomized into two groups. In the first group (n=86) during the preparation for PCI, we performed RIPC procedure by inflation of the cuff of the tonometer to 200 mm Hg and its further deflation on patient's shoulder, thus creating short cycles of controlled ischemia/reperfusion in hand (4 cycles of ischemia/reperfusion for 5/5 minutes respectively). In the second, control group (n=87), the standard primary PCI was performed without the previous RIPC. Evaluation of the endothelial function was performed on the 2-7th day after admission using the endothelium - dependent flow - mediated dilatation test (FMD) of the brachial artery. Primary endpoints in this study included the presence of ED, in - hospital mortality, life - threatening arrhythmias (ventricular fibrillation/ventricular tachycardia after first 24 hours upon admission), stent thrombosis, clinical signs of heart failure, and a combined endpoint consisting of all the listed above. Results. The median values for FMD-test did not differ significantly between the study groups upon admission. Assessment of the FMD of the brachial artery on the 2-7th day after PCI showed that among the patients who underwent RIPC there was a significantly lower percentage of patients with ED than in the patients with STEMI who did not undergo RIPC before PCI (43.1% vs. 75.8% respectively, p=0.0001). We found a significant reduction in the incidence of heart failure and of combined endpoint in the group of patients without ED compared with patients with ED: 0% vs. 9.3% (n=7; p=0.023) and 3.8% (n=2) vs. 16% (n=12; p=0.032) respectively. When assessing the effect of RIPC on hospital prognosis, we also found a significant decrease in the incidence of heart failure and a trend towards a decrease in the combined endpoint in the group of patients who underwent RIPC compared to the control group: 1.5% (n=1) vs. 9.7% (n=6; p=0.045) and 6.2% (n=4) vs. 16.1% (n=10; p=0.073) respectively. Conclusion. Performance of RIPC before the primary PCI significantly reduces the incidence of ED in patients with STEMI on the 2-7th day of the disease onset. The presence of ED in patients with STEMI is associated with a significant increase in the incidence of heart failure and of the combined endpoint during in - hospital period. RIPC significantly reduces the incidence of heart failure in patients with STEMI during in - hospital period.
Terapevticheskii arkhiv. 2020;92(1):10-14
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Psychosocial risk factors for cardiovascular disease: gender differences and 22-year dynamics among the population of Siberia (WHO MONICA-Psychosocial Program, HAPIEE)

Gafarov V.V., Gagulin I.V., Gafarova A.V., Panov D.O., Krymov E.A., Gromova E.A.


Aim. To determine the gender differentiation and dynamics for 22 years of psychosocial factors (PSF) of the risk of cardiovascular disease among the population aged 25-64 years in Russia / Siberia (Novosibirsk). Materials and methods. Representative samples of the population of the city of Novosibirsk under the program of the World Health Organization “MONICA-MOPSY” in 1994-1995 were examined. III screening (men - 657, women - 870, 25-64 years old); IV screening project HAPIEE in 2003-2005 (men - 576, women - 1074, 45-64 years old) and V screening in 2013-2016. (men - 427, women - 548, 25-44 years old). We used Spielberger tests, MONICA-MOPSY tests, the Breckman - Sim test, the “Knowledge and attitude to your health” questionnaire. Results. In an open population of 25-64 years old, high levels of anxiety (T), depression (D), life exhaustion (LM), and hostility (B) were higher in women than in men. In the group of 55-64 years over 10 years, women have increased personality T, decreased D and LM. Over 22 years, in the group of 25-34 years, men and women decreased T and MI, but D and B increased, while women decreased T, LM and B and D. grew. Low and high close contact indices were higher among men. A low index of social ties prevailed in men, and a high index in women. High levels of stress in the family were more common in women, and at work - in men. For 10 years, the level of stress in the family and at work in men has decreased. Sleep disorders in the population in all age groups were more often in women. Conclusion. It was found that women have significantly higher PSF than men, with the exception of stress at work. The decrease in PSF in women and men in the dynamics
Terapevticheskii arkhiv. 2020;92(1):15-24
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Role of preoperative cardiology consultation in patients undergoing cancer surgery

Sumin A.N., Starovojtova A.V., Scheglova A.V., Gorbunova E.V.


Aim. To evaluate the effects of preoperative cardiology consultation on the risk of perioperative cardiac complications in patients undergoing cancer surgery. Materials and methods. 74 patients with bronchial, lung, mediastinal and gastrointestinal cancer were referred to the cardiologist as a part of the preoperative management. Patients were assigned either to Group 1 (n=21), who required non - invasive testing or invasive coronary angiography (CAG), or to Group 2 (n=53), who did not have any indications to additional testing. Results. The median age was 65.8 years in Group 1 and 64.5 years in Group 2, p=0.408. Group 1 patients had higher RCRI than Group 2 patients (7.4±4.5 vs. 2.9±4.5, respectively, p=0.002). Four (19.05%) patients in Group 1 underwent minimally invasive examination without any further indications to CAG. 16 (76.2%) patients underwent CAG. Of them, 5 (23.8%) patients had severe coronary artery stenosis, and 4 (19.0%) patients had severe brachycephalic artery stenosis (≥50%). After CAG findings, one carotid artery and three coronary arteries (14.3%) were stented. Drug therapy was prescribed to one patient. One patient required stenting after the treatment of the underlying disease. Group 2 patients were more likely to achieve the endpoints - heart rhythm disturbances, decompensation of chronic heart failure, cardiac death (5.45% in Group 2 vs. 4.76% in Group 1, p>0.05). Multivariate analysis reported that angina pectoris was an independent factor to refer patients to the additional testing (p<0.001). Conclusion. 28% of patients undergoing cancer surgery required additional testing. Of them, 21.6% underwent CAG. 6.8% of patients had severe coronary artery stenosis. Of them 4% underwent myocardial revascularization before cancer surgery. This approach allowed minimizing the number of perioperative cardiac complications.
Terapevticheskii arkhiv. 2020;92(1):25-29
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The effectiveness of pancreatic enzyme replacement therapy using microencapsulated pancreatin preparations in the correction of nutritional status in patients with chronic pancreatitis: a prospective observational study

Bideeva T.V., Maev I.V., Kucheryavyy Y.A., Andreev D.N., Shah Y.S., Lobanova E.G., Zaborovskiy A.V., Levchenko A.I.


Aim. The goal is to evaluate the effectiveness of pancreatic enzyme replacement therapy (PERT) using microencapsulated pancreatin preparations for the correction of nutritional status in patients with chronic pancreatitis (CP) and associated exocrine pancreatic insufficiency (EPI). Materials and methods. The study included 58 patients with CP who were divided into two groups depending on the results of a laboratory assessment of indicators of nutritional status: group I (n=30) consisted of patients with CP and signs of EPI (according to low elastase test values) without deviations in nutritional status; Group II (n=28) consisted of patients with CP with a EPI and an abnormal nutritional status. In both groups, patients during the entire observation period (8-12 months) received PERT using microencapsulated pancreatin preparations at a dose adjusted for the severity of permanent residence permit. Before and after the PERT course, the dynamics of anthropometric [body weight, body mass index (BMI)] and laboratory indicators of nutritional status (total protein, albumin, vitamins D and B12, transferrin, iron and magnesium) were evaluated. Results. After the completion of PERT, a significant tendency towards an increase in BMI in patients was noted in both groups. In group I, this indicator increased from 21.45 [95% confidence interval (CI) 19.80-23.92] kg/m2 to 22.15 (95% CI 20.31-23.86) kg/m2, and in II group - from 19.22 (95% CI 18.33-21.99) kg/m2 to 22.0 (95% CI 19.97-24.08) kg/m2. At the same time, the duration of PERT (months) significantly correlated with the dynamics of the patient’s body weight (r=0.4679; 95% CI 0.2384-0.6479, p=0.0002). When assessing laboratory markers of nutritional status after PERT, a general tendency was found to increase the levels of total protein, albumin, vitamin D, magnesium, transferrin, and iron in both groups, however, statistically significant differences in the dynamics were observed mainly in group II patients. So, the level of total protein in group II increased from 69.05 (95% CI 65.6717-70.9000) g/l to 72.8 (95% CI 71.1358-74.9000) g/l, vitamin D - from 10.6 (95% CI 32.8397-38.9603) ng/ml to 17.1 (95% CI 12.0166-23.6232) ng/ml, magnesium - from 0.72 ( 95% CI 0.6892-0.7825) mmol/L to 0.795 (95% CI 0.7692-0.8800) mmol/L, and transferrin from 2.91 (95% CI 2.1800-3.3656 ) g/l to 2.92 (95% CI 2.4000-3.5200) g/l. Conclusion. A prospective observational study demonstrated the effectiveness of PERT using microencapsulated pancreatin preparations in the correction of nutritional status in patients with CP.
Terapevticheskii arkhiv. 2020;92(1):30-35
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Etiology of severe community - acquired pneumonia in adults: results of the first Russian multicenter study

Zakharenkov I.A., Rachina S.A., Dekhnich N.N., Kozlov R.S., Sinopalnikov A.I., Ivanchik N.V., Yatsyshina S.B., Elkina M.A., Archipenko M.V., Gordeeva S.A., Lebedeva M.S., Portnyagina U.S.


Aim: to study the etiology of severe community - acquired pneumonia (SCAP) in adults in Russian Federation. SCAP is distinguished by high mortality and socio - economic burden. Both etiology and antimicrobial resistance are essential for appropriate antibiotic choice. Materials and methods. A prospective cohort study recruited adults with confirmed diagnosis of SCAP admitted to multi - word hospitals of six Russian cities in 2014-2018. Etiology was confirmed by routine culture of blood, respiratory (sputum, endotracheal aspirate or bronchoalveolar lavage) and when appropriate, autopsy samples, urinary antigen tests (L. pneumophila serogroup 1, S. pneumoniae); real - time PCR for identification of “atypical” bacterial pathogens (M. pneumoniae, C. pneumoniae, L. pneumophila) and respiratory viruses (influenza viruses A and B, parainfluenza, human metapneumovirus, etc.) was applied. Results. Altogether 109 patients (60.6% male; mean age 50.8±18.0 years old) with SCAP were enrolled. Etiological agent was identified in 65.1% of patients, S. pneumoniae, rhinovirus, S. aureus and K. pneumoniae were the most commonly isolated pathogens (found in 43.7, 15.5, 14.1 and 11.3% of patients with positive results of microbiological investigations, respectively). Bacteriemia was seen in 14.6% of patients and most commonly associated with S. pneumoniae. Co - infection with 2 or more causative agents was revealed in 36.6% of cases. Combination of bacterial pathogens (mainly S. pneumoniae with S. aureus or/and Enterobacterales) prevailed - 57.7% of cases; associations of bacteria and viruses were identified in 38.5% of patients, different viruses - in one case. Conclusion. S. pneumoniae was the most common pathogen in adults with SCAP. A high rate of respiratory viruses (mainly rhinovirus and influenza viruses) identification both as mixt infection with bacteria and mono - infection should be taken into account.
Terapevticheskii arkhiv. 2020;92(1):36-42
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The possibilities of using levosimendan in medical preparation to Coronary Artery Bypass Grafting in coronary artery disease patients with low left ventricular ejection fraction

Gazizova V.P., Vlasova E.E., Dzybinskaya E.V., Gramovich V.V., Stukalova O.V., Shiryaev A.A., Akchurin R.S.


Aim: to work out an approach of preoperative drug preparation for CAD patients with low LVEF and varying degrees of compensation for CHF, to study the possibility of using levosimendan (L) in this preparation. Materials and methods. We studied 82 patients with severe angina pectoris, multivascular coronary disease, extensive postinfarction zone, LVEF ≤35%, chronic heart failure and proven viable myocardium, which performed CABG. All patients received long - term standard CHF therapy before surgery: loop diuretic, ACE/ARA, beta - blocker, aldosterone antagonist. In the first, retrospective part of the study (39 pts), it was determined which factors could be associated with perioperative AHF. In the second, prospective part (43 pts), the course of the operation and the early postoperative period in patients with compensated and uncompensated heart failure were compared; uncompensated pts received L 2 days before surgery in addition to standard therapy. The third, retro - prospective part of the study (37 pts) was the assessment of operation outcome in patients only with uncompensated pre - operative CHF, but with different preoperative drug preparation. Results. Statistically significant direct influence on the perioperative AHF development was provided by the combined clinical sign - venous pulmonary congestion+orthopnea (p<0.01). Patients with this sign presence, i.e. with uncompensated CHF, were infused with L before surgery; in this case the operation outcomes and the early postoperative period were similar to those in patients initially compensated; the only significantly different parameter was the Vasoactive Inotropic Score (VIS) at the end of the surgery (p=0.03). The effect of L was confirmed in the analysis of patients only with uncompensated CHF: those receiving L had significantly (p<0.05) lower VIS, inotropic support duration, time spent in ICU and hospital stay. Conclusion. For CABG candidates with low LVEF and uncompensated CHF preoperative use of levosimendan is advisable; it improves the operation outcome and the course of the early postoperative period.
Terapevticheskii arkhiv. 2020;92(1):43-48
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Assessment of the clinical efficacy of telemonitoring and distant counseling in patients with uncontrolled hypertension

Ionov M.V., Zhukova O.V., Zvartau N.E., Kurapeev D.I., Yudina Y.S., Konradi A.O.


The aim of the study was to investigate the mathematical correlation of the clinical efficacy of blood pressure telemonitoring and distant counseling (BPTM) in patients in uncontrolled hypertension (HTN). Telehealth tools are widely used in HTN management. However clinical efficacy of such interventions assessed mainly in groups investigated without its populational and attributable impact. Materials and methods. The total of 240 patients were included, then randomized in 2:1 manner to BPTM group (n=160, median age 47 y.o.) and control group (n=80, median age 49 y.o). The user - friendly and secure telehealth software was provided with mobile application (patients) and desktop (doctors) platforms which allowed storage and analysis of self-BP monitoring data and remote consultations. A three - month surveillance was designed with mandatory baseline and final face - to - face visits with the assessment of office systolic BP (oSBP). Mathematical evaluation was based on target SBP rates achieved in comparator groups and included the absolute efficacies (AE), the attributable efficacy (AtE), the relative efficacy (RE) and the population attributable efficacy (PAtE). Results. BPTM group characterized by larger decrease in SBP level compared with controls (-16.8±2.9 mm Hg versus -7.9±3.9 mm Hg; p<0.001). There were 120 and 16 patients with SBP on target by the end of the study in BPTM and control group respectively (AE 75±6.7% versus 20±8.8%, p<0.001). AtE was found to be 55.0±11.3%; RE was estimated as 3.75 (95% CI 1.94-5.56) and PAtE was found to be 36.7% (95% CI 24.1-49.2). Number needed to treat to achieve target BP with BPTM was estimated as 1.8. Conclusion. Implementing BPTM into management strategy significantly increases the likelihood of BP control. The results of the study indicate a pronounced effect of BPTM on the achievement of target BP.
Terapevticheskii arkhiv. 2020;92(1):49-55
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Assessment of external risk factors of hepatocellular cancer development and markers of genetic predisposition to its development in the ethnic group of yakut - men

Yushchuk N.D., Sleptsova S.S., Malov S.I., Bilukina I.F., Semenov S.I., Stepanenko L.A., Ogarkov O.B., Savilov E.D., Malov I.V.


Aim. To establish the main external and genetically determined risk factors for the development of hepatocellular cancer in the ethnic group of male Yakuts living in the Republic of Sakha (Yakutia) [RS (Y)] in the epidemiologically unfavorable conditions of the incidence of viral hepatitis. Materials and methods. A total of 97 male Yakuts were examined, including 44 people diagnosed with hepatocellular cancer and 53 people diagnosed with chronic viral hepatitis. HCC risk factors were identified by analyzing medical records and questioning patients. In the experimental and control groups, genetic studies of single nucleotide polymorphisms of genes mapped on the X-chromosome and involved in the activation of antiviral immunity along the TLR7 signaling pathway were performed. Results and discussion. In 100% of patients with hepatocellular cancer, infection with hepatitis B, C, D viruses or co - infection with these agents was detected. Every fourth patient with HCC in the RS (Y) was infected with hepatitis D. The course of hepatocellular cancer associated with HDV was characterized by rapid progression of liver cirrhosis, development of portal hypertension, bleeding from varicose veins of the stomach and esophagus (36.4%) and edematous ascitic syndrome (63.6%). In addition to viral agents, additional risk factors for liver cancer were identified, such as alcohol abuse, overweight, diabetes mellitus, and smoking. Among the studied variation sites of genes localized on the X-chromosome and encoding the reaction of innate antiviral immunity, no genetic marker was found with a sufficient degree of confidence determining the likelihood of hepatocellular cancer developing. Conclusions. The high incidence of hepatocellular carcinoma of the male population in the RS (Y) is due to the widespread prevalence of parenteral viral hepatitis, especially viral hepatitis D. Due to the introduction of mass vaccination of the population against hepatitis B in the Russian Federation in the foreseeable future in the RS (Y) we should see a decrease in the proportion of hepatocellular cancer associated with hepatitis B and D viruses, and therefore the focus should be on the treatment and prevention of hepatitis C virus and non - infectious risk factors.
Terapevticheskii arkhiv. 2020;92(1):56-61
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Frailty syndrome. What physicians and cardiologists need to know?

Krivoshapova K.E., Vegner E.A., Barbarash O.L.


The review presents the data and evidences from recent clinical studies on the frailty syndrome - one of the most relevant clinical syndromes, though not studied well yet. The latest data on the prevalence of frailty and various factors contributing to its onset are reported. The presence of frailty is considered as an independent predictor of poor prognosis and high mortality rate. The role of frailty in the development of cardiovascular diseases, their progression and complicated course has been analyzed using the latest studies. In addition, the tendency towards higher incidence of frailty among the population of different countries and the poor prognosis of frail patients requires a series of clinical studies aimed at developing measures for primary and secondary prevention, as well as effective treatment strategies for frailty. The PubMed was used for a literature review.
Terapevticheskii arkhiv. 2020;92(1):62-68
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Hypertension and insomnia

Ostroumova T.M., Parfenov V.A., Ostroumova O.D., Kochetkov A.I.


Insomnia is frequently detected in patients with arterial hypertension (AH): from 19% to 47.9% of all cases according to epidemiological studies. On the other hand, the frequency of hypertension in patients with insomnia ranges from 21.4% to 50.2%, whereas in patients without insomnia, from 11.0% to 41.8%. In single studies in which patients with insomnia underwent ambulatory blood pressure monitoring (ABPM), these patients showed higher nocturnal blood pressure levels. Recent data suggests that insomnia is also a risk factor for hypertension. Among the pathogenetic mechanisms explaining the relationship between hypertension and insomnia, an increase in the activity of the main neuroendocrine stress systems, sympatho - adrenal and hypothalamic - pituitary - adrenal, and the frequent presence of concomitant anxiety disorders are discussed. To determine the sleep quality in patients with insomnia, the Pittsburgh Sleep Quality Index (PSQI) is most often used, patients with hypertension in a number of studies had higher total PSQI score compared to individuals with normal blood pressure. PSQI score correlates with systolic and diastolic blood pressure level, as well as with the presence of non - dipper blood pressure profile. Both hypertension and insomnia are associated with impaired cognitive functions. However, the relationship between cognitive impairment and insomnia is rather contradictory, which is most associated with the methodology for assessing cognitive functions and differences in the initial clinical and demographic characteristics of the examined patient population.
Terapevticheskii arkhiv. 2020;92(1):69-75
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Pancreatic diseases and inflammatory bowel diseases: a random or regular combination?

Akhmedov V.A., Gaus O.V.


Pathology of the pancreas in inflammatory bowel disease (IBD) is more common than in the general population and includes a wide range of manifestations from asymptomatic to severe disorders. Acute pancreatitis, chronic pancreatitis, autoimmune pancreatitis, exocrine pancreatic insufficiency, increased pancreatic enzymes and structural duct anomalies are often associated with IBD. They can be either a manifestation of IBD itself or develop independently.
Terapevticheskii arkhiv. 2020;92(1):76-81
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The use of nonsteroidal anti - inflammatory drugs in polymorbid pathology

Asfandiyarova N.S., Philippov E.V.


The literature review presents the possibilities of using non - steroidal anti - inflammatory drugs (NSAIDs) for polymorbid pathology. The mechanism of NSAIDs action, risk factors for the development of undesirable effects on the cardiovascular, digestive, urinary and other systems are considered; prevention measures and drug selection options are discussed, NSAIDs prescribing algorithm is considered.
Terapevticheskii arkhiv. 2020;92(1):82-88
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The concept of chronic obstructive pulmonary disease clinical control as a decision - making tool in real clinical practice for optimizing of basic pharmacotherapy

Avdeev S.N., Aisanov Z.R., Belevsky A.S., Beeh K.M., Vizel A.A., Zyryanov S.K., Ignatova G.L., Kostikas K., Leshchenko I.V., Ovcharenko S.I., Sinopal’nikov A.I., Titova O.N., Shmelev E.I.


The main goals of COPD therapy are to achieve clinical stability with minimal clinical manifestations and low risk of relapse. The proposed COPD control concept by analogy with asthma has not been quite well characterized yet. COPD control is defined as "the long - term maintenance of a clinical situation with a low impact of symptoms on the patient’s life and absence of exacerbations." The situation of clinical control in COPD is considered desirable and potentially achievable for most patients with COPD. Pharmacotherapeutic options for COPD are constantly expanding. The control concept may be useful when the decision on treatment of COPD is made for dynamic adjustment of the therapy volume.
Terapevticheskii arkhiv. 2020;92(1):89-95
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