Chronic Heart Failure in Patients Hospitalized in 2002 and 2021: Comparative Analysis of Prevalence, Clinical Course and Drug Therapy

AIM

Comparative analysis of the prevalence of chronic heart failure (CHF), clinical and medical history data, and drug therapy of patients admitted to a cardiology hospital in 2002 and 2021.

MATERIAL AND METHODS

The study analyzed the medical records of patients with a confirmed diagnosis of CHF who were admitted in 2002 (n=210) and 2021 (n=381) to a specialized cardiology hospital.

RESULTS

According to medical records of 2021, the proportion of patients with a confirmed diagnosis of CHF (87.6%) in the cohort of patients admitted to a cardiology hospital was twice as high as in 2002 (46.4%; p<0.001). The majority of patients with CHF in the study sample were patients with preserved left ventricular ejection fraction (HFpEF). The proportion of such patients significantly increased to reach 75.9% in 2021 compared to 58.6% in 2002 (p<0.001). At the same time, the number of severe forms of CHF (NYHA functional class (FC) IV) decreased by 10% and was 13.2% in 2002 and 1.3% in 2021 (p<0.001). In the majority of patients, ischemic heart disease (98.1 and 91.1% in 2002 and 2021, respectively, p<0.001) and hypertension (80.5 and 98.2%, respectively, p<0.001) were diagnosed as the cause for CHF. Furthermore, the incidence of comorbidity increased significantly: atrial fibrillation was detected in 12.3% of patients in 2002 and 26.4% in 2021 (p < 0.001); type 2 diabetes mellitus, in 14.3 and 32% of patients (p <0.001); and obesity, in 33.3 and 43.7% of patients, respectively (p=0.018). The frequency of using the major groups of drugs increased during the analyzed period: renin-angiotensin-aldosterone system blockers were administered to 71.9% of patients in 2002 and to 87.7% in 2021 (p<0.001); beta-blockers were administered to 53.3 and 82.4% of patients (p<0.001); and mineralocorticoid receptor antagonists, to 1.9 and 18.6% of patients, respectively (p=0.004).

CONCLUSION

In 2021, the proportion of patients with a confirmed diagnosis of CHF in the patient cohort admitted to a cardiology hospital was twice as high as in 2002; the phenotype with preserved left ventricular ejection fraction predominated in the CHF structure. During the analyzed twenty-year period, the prevalence of comorbidities increased among CHF patients. The prescription frequency of pathogenetic evidence-based therapy has significantly increased by 2021, however, it remains insufficient even in patients with CHF with reduced left ventricular ejection fraction.

Female and Male Phenotypes of Iron Deficiency in CHF. Additional analysis of the «The Prevalence of Iron Deficiency in Patients With Chronic Heart Failure in the Russian Federation (J-CHF-RF)» study

Aim    To evaluate the incidence of iron deficiency (ID) in men and women with chronic heart failure (CHF) and to compare clinical and functional indexes in patient with and without ID depending on the gender.Material and methods    An additional analysis of the study "Prevalence of Iron Deficiency in Patients With Chronic Heart Failure in the Russian Federation (ID-CHF-RF)" was performed. The study included 498 (198 women, 300 men) patients with CHF, in whom, in addition to iron metabolism, the quality of life and exercise tolerance (ET) were studied. 97 % of patients were enrolled during their stay in a hospital. ID was defined in consistency with the European Society of Cardiology (ESC) Guidelines. Also, and additional analysis was performed according to ID criteria validated by the morphological picture of the bone marrow.Results    ID was detected in 174 (87.9 %) women and 239 (79.8 %) men (p=0.028) according to the ESC criteria, and in 154 (77.8 %) women and 217 (72.3 %) men (p=0.208) according to the criteria validated by the morphological picture of the bone marrow. Men with ID were older and had more severe CHF. They more frequently had HF functional class (FC) III and IV (63.4 % vs. 43.3 % in men without ID); higher concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) and lower ET. HF FC III increased the probability of ID presence 3.4 times (p=0.02) and the probability of HF FC IV 13.7 times (p=0.003). This clinical picture was characteristic of men when either method of determining ID was used. In women, ID was not associated with more severe CHF.Conclusion    Based on the presented analysis, it is possible to characterize the male and female ID phenotypes. The male ID phenotype is associated with more severe CHF, low ET, and poor quality of life. In females of the study cohort, ID was not associated with either the severity of CHF or with ET.

[Androgenic status of men with severe COVID-19: the role of testosterone and dihydrotestosterone [within the program FOUNDER (features of a new coronavirus infection course and options therapy depending on the androgenic status)]]

PURPOSE

The aim of this study was to assess the mens androgen status influence on the severity and outcomes (transfer of patients to the ICU or death) of COVID-19 required hospital hospitalization.

MATERIALS AND METHODS

The study included 151 hospitalized men with a confirmed diagnosis of COVID-19. To measure the severity of disease have been used Symptomatic Hospital and Outpatient Clinical Scale for COVID-19 (SHOCS-COVID). It includes the severity of the clinical condition (hyperthermia, shortness of breath, oxygen saturation, need for ventilation), the degree of inflammation (CRP), markers of thrombosis (D-dimer), the degree of lung damage according to CT. The patients underwent a study of full blood count, some biochemical parameters, lung CT, and a study of testosterone (T) and dihydrotestosterone (DHT) levels.

RESULTS

T deficiency was observed in 46.4% of patients (70/151 men). At the same time, DHT deficiency was observed only in 14.4% of patients (18/125 men). In patients with a T level below the median, there was a significant increase in inflammatory factors (CRP, lymphocytes/CRP index), markers of thrombosis (D-dimer and fibrinogen), extensive lung damage at admission according to CT 25.75% vs. 11.95% (p<0.001), the elevated number of points for SHOCKS-COVID 7 (IQR 5-10) versus 5 (IQR 3-7) (p<0.001) and the longer duration of hospital treatment (3 days difference, p<0.001) in comparison with a group of patients with a T level above the median. At the same time, the T level had no correlation with age. The level of DHT had a weak inverse correlation with the age of patients, but not with the main markers of the severity of COVID-19, including the number of SHOCK-COVID scores. During multivariate regression analysis, it was shown that SHOCKS-COVID is the most significant predictor of admission to the ICU while no association of T and DHT levels with outcomes in COVID-19 was found. However, it was found that the concentration of T, even adjusted for age, has a significant inverse association with the severity of the course of the disease and the number of SHOCK-COVID scores (p=0.041). An analysis of the evaluation of directed acyclic graphs suggests the main role of COVID-19 severity in reducing androgenic function and T concentration, at which its anti-inflammatory effects are lost. There were no correlations between the concentration of DHT and the number of SHOCK-COVID scores and the COVID-19 prognosis.

CONCLUSION

SHOCK-COVID is the most sensitive predictor of the COVID-19 outcome in hospitalized men, including adjusting to age. T and DHT do not directly affect the outcomes of the disease. The greater severity of the infection and an increase in SHOCK-COVID scores are associated with a decrease in the concentration of T, and a weakening of its anti-inflammatory and anti-cytokine effects, which indirectly worsens the prognosis of male patients with a new coronavirus infection undergoing hospital treatment. There are no such relationships for DHT.

[What is "normal left ventricular ejection fraction" and its relationship with the pathogenesis and effectiveness of the treatment of heart failure]

The article focuses on modern views on the role and place of left ventricular ejection fraction (LV EF) in determining the status of cardiovascular patients (primarily patients with heart failure) in the algorithm for their diagnosis, treatment, and prediction of the outcome. Conclusions and recommendations on the use of LV EF in patients with chronic heart failure (CHF) are the following: 1) LV EF remains a familiar and convenient instrumental indicator not so much of myocardial contractility as of hemodynamics in general. Assessment of LV EF is useful for selection and ranking of CHF patients whereas the LV EF dynamics is useful for assessing the quality of their management. 2) In the entire population of cardiovascular patients, the "normal" LV EF (mortality nadir) is in the range of 60-65%. 3) LV EF demonstrates a U-shaped relationship with prognosis: in cardiovascular patients with LV EF below the mortality nadir, the relationship is inversely proportional, and above the mortality nadir, it is directly proportional. The question of the boundary between "normal" and "reduced" LV EF in terms of CHF syndrome remains open, but obviously, this boundary is most likely within the range of 50 to 60%. 4) LV EF determines the effectiveness of CHF treatment, but this rule is not applicable to all LV EF ranges and not to all classes of drugs.

[Prospects for use of Vericiguat in HFrEF: Implications of VICTORIA Trial Results. Advisory Board Summary]

In September 2021, an online meeting of the Council of Experts was held. The proposed focus of discussion was publishing the results of an international prospective, randomized, double-blind, placebo-controlled study VICTORIA. The objective of the VICTORIA study was evaluation of the efficacy and safety of supplementing a standard therapy with vericiguat at a target dose of 10 mg twice a day as compared to placebo for prevention of cardiovascular death and hospitalization for heart failure (HF) in patients with clinical manifestations of chronic HF and left ventricular ejection fraction &lt;45% who have recently had an episode of decompensated HF. The aim of the meeting was interpretation of the VICTORIA study results on efficacy and safety of vericiguat for a potential use in a Russian population of patients after a recent episode of decompensated chronic HF with reduced ejection fraction.

[Cardiovascular effects of omega-3 polyunsaturated fatty acids: position of omega-3 polyunsaturated fatty acids in Russian and international guidelines. Council of Experts]

This Expert Council focuses on the meta-analysis of studies on the risk of atrial fibrillation (AF) in patients taking omega-3 polyunsaturated fatty acids (PUFA) and of data on the omega-3 PUFA treatment in patients with cardiovascular and kidney diseases.The major statements of the Expert Council: the meta-analysis of AF risk in patients taking omega-3 PUFA showed an increased risk of this arrhythmia. However, it should be taken into account that the risk of complications was low, and there was no significant increase in the risk of AF when omega-3 PUFA was used at a dose of ≤1 g and a standard dose of the only omega-3 PUFA drug registered in the Russian Federation, considering all AF episodes in the ASCEND study.At the present time, according to Russian and international clinical guidelines, the use of omega-3 PUFA can be considered in the following cases: • for patients with chronic heart failure (CHF) with reduced left ventricular ejection fraction as a supplement to the basic therapy (2B class of recommendations according to the 2020 Russian Society of Cardiology guidelines (RSC) and the 2022 AHA / ACC / HFSA guidelines); • for patients with hypertriglyceridemia (&gt;1.5 mmol/l) as a part of combination therapy (IIb class of recommendations and B level of evidence according to the 2021 European guidelines on cardiovascular disease prevention, etc.); • for adult patients with stage 3-4 chronic kidney disease (CKD), long-chain omega-3 PUFA 2 g/day is recommended for reducing the level of triglycerides (2C class of recommendations). Data on the use of omega-3 PUFA for other indications are heterogenous, which can be partially explained by using different form and doses of the drugs.

Proactive anti-inflammatory therapy in the advanced stages of a new coronavirus infection. Main results of the inpatient phase of the COLORIT study (Colchicin vs. Ruxolitinib and secukinumab in an open, prospective, randomized trial in patients with novel coronavirus infection COVID-19)

Aim      To evaluate clinical efficacy of the proactive anti-inflammatory therapy in patients hospitalized for COVID-19 with pneumonia and a risk of "cytokine storm".Material and methods  The COLORIT study was a comparative study with randomization into 4 groups: colchicine (n=21) 1 mg for the first 3 days followed by 0.5 mg/day through day 12 or discharge from the hospital; secukinumab 300 mg/day, s.c., as a single dose (n=20); ruxolitinib 5 mg, twice a day (n=10); and a control group with no anti-inflammatory therapy (n=22). The effect was evaluated after 12±2 days of inpatient treatment or upon discharge, what comes first. For ethical reasons, completely randomized recruitment to the control group was not possible. Thus, for data analysis, 17 patients who did not receive any anti-inflammatory therapy for various reasons not related with inclusion into the study were added to the control group of 5 randomized patients. Inclusion criteria: presence of coronavirus pneumonia (positive PCR test for SARS-CoV-2 RNA or specific clinical presentation of pneumonia; IDC-10 codes U07.1 and U07.2); C-reactive protein (CRP) concentration &gt;60 mg/l or its threefold increase from baseline; at least 2 of 4 symptoms (fever &gt;37.5 °C, persistent cough, shortness of breath with inspiratory rate &gt;20 per min or blood saturation with oxygen &lt;94 % by the 7th-9th day of disease. The study primary endpoint was changes in COVID Clinical Condition Scale (CCS-COVID) score. The secondary endpoints were the dynamics of CRP and changes in the area of lung lesion according to data of computed tomography (CT) of the lungs from the date of randomization to 12±2 days.Results All three drugs significantly reduced inflammation, improved the clinical course of the disease, and decreased the disease severity as evaluated by the CCS score: in the ruxolitinib group, by 5.5 (p=0.004); in the secukinumab group, by 4 (p=0.096); in the colchicine group, by 4 (p=0.017), and in the control group, by 2 (р=0.329). In all three groups, the CCS-COVID score was 2-3 by the end of observation period, which corresponded to a mild process, while in the control group, the score was 7 (р=0.005). Time-related changes in CRP were significant in all three anti-inflammatory treatment groups with no statistical difference between the groups. By the end of the study, changes in CT of the lungs were nonsignificant.Conclusion      In severe СOVID-19 with a risk of "cytokine storm", the proactive therapy with ruxolitinib, colchicine, and secukinumab significantly reduces the inflammation severity, prevents the disease progression, and results in clinical improvement.

[Not Available]

PURPOSE

Assessment of COVID-19 incidence and hospitalization rate of male patients with prostatic hyperplasia depending on the intake of 5-alpha-reductase inhibitors (5-ARI).

MATERIALS AND METHODS

In our study, electronic medical records of 1678 patients with prostatic hyperplasia were analyzed. 1490 men aged 71 (64-76) years were selected for final analysis. Vaccination against COVID-19 was carried out in 730 patients (49%). Treatment with 5-ARI inhibitors was carried out in 269 (18.1%) patients.

RESULTS

Among 1490 included patients 790 (53%) had COVID- 19 while 360 (45.7%) of them required hospitalization. During the multivariate analysis, only two factors were associated with the risk of COVID-19 in the cohort studied: vaccination (odds ratio (OR) =0.095; 95% confidence interval (CI) 0.074-0.122), i.e. a 90.5% chance reduction, p<0.001) and the fact of taking 5-ARI (OR=0.235; 95%CI=0.165-0.335; p<0.001), i.e. a 76.5% chance reduction. The duration of 5-ARI therapy was not associated with the incidence of new coronavirus infection. The severe course of COVID-19 which required hospitalization was positively associated with age (p=0.025) and the presence of coronary artery disease (p=0.004); and negatively associated with the frequency of vaccination (p<0.001) and treatment of 5-ARI (3.1% vs. 11.6%, p<0.001). In a multivariate analysis of outpatient patients with prostatic hyperplasia who had COVID-19, 5-ARI intake (OR=0.240; 95% CI 0.122-0.473; p<0.001) and vaccination (OR = 0.570; 95% CI 0.401-0.808; p=0.002). The factors associated with increased chances of hospitalization due to the severe course of COVID-19 were coronary heart disease (+43.8%, p=0.019) and older age (+1.7% by one year, p=0.046).

CONCLUSION

Taking 5-ARI, along with vaccination in patients with prostatic hyperplasia is a protective factor for morbidity and the severity of COVID-19.

[Coenzyme Q-10 in the treatment of patients with chronic heart failure and reduced left ventricular ejection fraction: systematic review and meta-analysis]

Aim    The aim of the study was evaluation of the effect of the coenzyme Q10 (Q10) treatment on all-cause and cardiovascular mortality of patients with chronic heart failure (CHF). Q-10 increases the electron transfer in the mitochondrial respiratory chain and exerts anti-inflammatory and antioxidant effects. These effects improve the endothelial function and reduce afterload, which facilitates the heart pumping function. Patients with reduced left ventricular (LV) ejection fraction (EF) (CHFrEF) have low Q10.Material and methods    Criteria of inclusion in the meta-analysis: 1) placebo-controlled studies; 2) enrollment of at least 100 patients; 3) publications after 2010, which implies an optimal basic therapy for CHF; 4) duration of at least 6 months; 5) reported cardiovascular and/or all-cause mortality; 6) using sufficient doses of Q10 (&gt;100 mg/day). The search was performed in CENTRAL, MEDLINE, Embase, Web of Science, E-library, and ClinicalTrials.gov databases. All-cause mortality was the primary efficacy endpoint in this systematic review and the meta-analysis. The secondary endpoint was cardiovascular mortality. Meta-analysis was performed according to the Mantel-Haenszel methods. The Cochrane criterion (I2) was used for evaluation of statistical heterogeneity. The random effects model was used at I2≥50 %, whereas the fixed effects model was used at I2&lt;50.Results    Analysis of studies published from 01.01.2011 to 01.12.2021 identified 357 publications, 23 of which corresponded to the study topic, but only 6 (providing results of four randomized clinical trials, RCT) completely met the predefined criteria. The final analysis included results of managing 1139 patients (586 received Q10 and 553 received placebo). Risk of all-cause death was analyzed by data of four RCTs (1139 patients). The decrease in the risk associated with the Q10 treatment was 36 % (OR=0.64, 95 % CI 0.48-0.87, р=0.004). The heterogeneity of studies was low (Chi2=0.84; p=0.84; I2=0 %). Risk of cardiovascular mortality was analyzed by data of two RCTs (863 patients). The decrease in the risk associated with the Q10 treatment was significant, 55% (OR=0.45, 95 % CI: 0.32-0.64, р=0.00001). In this case, the data heterogeneity was also low (Chi2=0.41; p=0.52; I2=0 %).Conclusion    The meta-analysis confirmed the beneficial effect of coenzyme Q10 on the prognosis of patients with CHFrEF receiving the recommended basic therapy.

[Iron deficiency in Russia heart failure patients. Observational cross-sectional multicenter study]

Aim    To evaluate the prevalence of iron deficiency (ID) in Russian patients with heart failure (HF).Material and methods    Iron metabolism variables were studied in 498 (198 women, 300 men) patients with HF. Data were evaluated at admission for HF (97 %) or during an outpatient visit (3 %). ID was determined according to the European Society of Cardiology Guidelines.Results    83.1 % of patients had ID; only 43.5 % of patients with ID had anemia. Patients with ID were older: 70.0 [63.0;79.0] vs. 66.0 years [57.0;75.2] (p=0.009). The number of patients with ID increased in parallel with the increase in HF functional class (FC). Among patients with ID, fewer people were past or current alcohol users (p=0.002), and a greater number of patients had atrial fibrillation (60.1 vs. 45.2 %, p=0.016). A multiple logistic regression showed that more severe HF (HF FC) was associated with a higher incidence of ID detection, whereas past alcohol use was associated with less pronounced ID. An increase in N-terminal pro-brain natriuretic peptide (NT-proBNP) by 100 pg/ml was associated with an increased likelihood of ID (odds ratio, 1.006, 95 % confidence interval: 1.002-1.011, p=0.0152).Conclusion    The incidence rate of HF patients is high in the Russian Federation (83.1 %). Only 43.5 % of these patients had anemia. The prevalence of ID in the study population increased with increases in HF FC and NT-proBNP.

Epidemiology of atrial fibrillation in a representative sample of the European part of the Russian Federation. Analysis of EPOCH-CHF study

Aim    To study true prevalence of atrial fibrillation (AF) in a representative sample from the European part of the Russian Federation; to describe characteristics of patients with AF; and to provide the frequency of anticoagulant treatment.Material and methods    Cross-sectional data of the EPOCH epidemiological study (2017) were used. Data were collected in 8 constituent entities of the Russian Federation; the sample size was 11 453 people. The sample included all respondents who had given their consent for participation and were older than 10 years. Statistical tests were performed in the R system for statistical data analysis.Results    The prevalence of AF in the representative sample from the European part of the Russian Federation was 2.04 %. The AF prevalence increased with age and reached a maximum value of 9.6% in the age group of 80 to 89 years. The AF prevalence among females was 1.5 times higher than among men. With age standardization, the AF prevalence was 18.95 and 21.33 per 1,000 people for men and women, respectively. The AF prevalence increased in the presence of concurrent cardiovascular diseases (CVDs) or diabetes mellitus as well as with an increased number of comorbidities in the same person and reached 70.3 and 60.0 % in patients with 4 and 5 comorbidities, respectively. Patients with AF had a greater number of comorbidities and higher CHA2DS2VASc scores (5.0 vs. 2.0, p&lt;0.001) compared to patients with CVDs without AF. Only 22.6 % of patients with CVD and AF took anticoagulants. Only 23.9% of patients with absolute indications for the anticoagulant treatment received anticoagulants.Conclusion    The AF prevalence in the European part of the Russian Federation was 2.04 %; it increased with age and in patients with concurrent CVDs or diabetes mellitus. Most of AF patients (93.2 %) required a mandatory treatment with oral anticoagulants.

Role of anticoagulants in therapy and prevention of recurrent venous thromboembolism in patients with cancer: a meta-analysis of randomized trials with apixaban

Background    Venous thromboembolic complications (VTEC) are a major non-oncological cause of death of patients with malignant neoplasm (MNP). This determines the high significance of antithrombotic therapy for the treatment and secondary prevention of VTEC in this population. During recent years, low-molecular weight heparins (LMWH) have been a "gold standard" for the treatment of cancer-associated venous thrombosis (CAVT). In the recent decade, direct oral anticoagulants (DOACs) have become extensively used for the treatment and prevention of VTEC relapse in non-oncological patients and also for primary prevention of VTEC following orthopedic surgery. Taking into account the oral route of administration, the predictable and convenient pharmacokinetic profile, and the absence of need for coagulation monitoring, it seems possible to use DOACs for the treatment and secondary prevention of VTEС in oncological patients. A meta-analysis of 4 randomized clinical trials (RCTs) showed a higher efficacy of DOACs compared to LMWHs, however, with a greater risk of bleedings in CAVT. In two of four studies using apixaban (more than 40% of weight in meta-analysis), no increase in bleedings was noted.Aim    The aim of this study was to perform a systematic search for comparative clinical studies with apixaban and to perform a meta-analysis to answer the question on clinical efficacy and safety of apixaban in the treatment and secondary prevention of recurrent VTEC in patients with CAVT.Material and methods    The systematic search was performed in three reference databases, Medline (PubMed), Cochrane Library (CENTRAL), and eLibrary. The search was aimed at publications containing results of RCTs using apixaban for the treatment and prevention of VTEC in patients with MNP. A totality of 678 titles was found; 15 articles were selected for detailed studying, and 4 RCTs were included into the final analysis. The meta-analysis was performed according to the criteria of PRISMA guidelines. Relative risk (RR) was used as a measure of the effect. The meta-analysis was performed by the Mantel-Haenszel method using the R software. Statistical heterogeneity was evaluated with the Cochran criterion (I2); heterogeneity was considered significant at I2 ≥50 %, which was a reason for performing a random-effects meta-analysis. For this meta-analysis, the primary outcome measure was new VTECs (symptomatic or detected proximal deep vein thrombosis and/or symptomatic, detected or fatal pulmonary thromboembolism plus symptomatic upper extremity thromboses, celiac veinous thromboses, and cerebral veinous thromboses if they were included into the efficacy endpoint of the primary studies). The primary safety measure was major bleeding according to ISTH criteria. Other variables included major and clinically significant minor bleedings as well as overall death rate.Results    During the systematic search, 4 RCTs were selected. The meta-analysis of the treatment and secondary prevention of VTEC in patients with MNP showed that apixaban was more effective than the active control (88% of LMWHs) in prevention of VTEC relapse. The RR was 0.59; 95 % confidence interval (CI): 0.40-0.86 in the absence of statistically significant differences from the control in the risk of major bleedings (statistically non-significant decrease by 21%), the sum of major and clinically significant minor bleedings, and overall death rate.Conclusion    According to the results of the meta-analysis, the DOAC apixaban may be a drug of choice for the treatment and prevention of VTEC relapse in patients with MNO.

[Features of a new corOnavirUs infection course and optioNs therapy DEpending on the andRogenic status (FOUNDER): androgenic status in men with COVID-19 and its relationship with the disease severity]

OBJECTIVE

Analysis of androgen status in men hospitalized with a moderate COVID-19 and its relationship with the severity of the disease.

MATERIALS AND METHODS

The study included 152 males with a confirmed diagnosis of COVID-19 based on the results of a positive PCR for the SARS-CoV-2 virus and/or computed tomography of the lungs hospitalized at the MSU University Clinic due to the moderate and severe COVID-19. Examination of the level of biochemical blood parameters (CRP, creatinine, urea, glucose, total testosterone (T)); CT of the lungs. To objectify the severity of the clinical symptoms, the NEWS2 distress syndrome severity scales and the original scale for assessing the clinical condition of patients with COVID 19 (SHOCS-COVID) were used.

RESULTS

The median T level in 152 examined patients was 2.14 [1.21; 3.40] ng/ml. In patients with a T level below the median, the CRP level was more than two times higher, and the D-dimer value was almost two times higher than in patients with T level above median. The duration of treatment in the hospital was longer in men with COVID 19 and an initial T level below the median than in patients with T about the median (13 days vs 10.5 days, p=0.003). Low T level was correlated with lung damage by lung CT. After improving the clinical condition, there was a linear increase in the level of T independent of its initial level.

CONCLUSION

Among men with moderate and severe COVID-19, a decreased testosterone level is detected in 46.7% of cases. Patients with low testosterone levels on admission have more severe COVID-19. A significant increase in testosterone level was observed after successful COVID-19 treatment without any special action regarding testosterone level.

[Focus ultrasound for cardiology practice. Russian consensus document]

This document is a consensus document of Russian Specialists in Heart Failure, Russian Society of Cardiology, Russian Association of Specialists in Ultrasound Diagnostics in Medicine and Russian Society for the Prevention of Noncommunicable Diseases. In the document a definition of focus ultrasound is stated and discussed when it can be used in cardiology practice in Russian Federation.

Mitral valve replacement and implantation of an extracardial mesh frame in patients with severe heart failure: results of a clinical study and a description of a clinical case 18 years after surgery

Aim    Dilated cardiomyopathy (DCMP) is a major cause for severe heart failure. Development of a combination (drug and surgery) treatment of this disease is relevant. This prospective observational study was aimed at evaluating short- and long-term results of extracardiac mesh implantation in DCMP patients with heart failure resistant to the optimum drug therapy.Material and methods    The extracardiac mesh ACOR-1 was implanted in 15 patients with DCMP. All meshes were produced individually for each patient and made of Gelweave (great Britain) vascular graft strips. The mesh size corresponded to the heart diastolic size, which was measured after achieving a maximum possible clinical improvement for the patient. Long-term results were followed for up to 4 years. Mean age of patients was 43.1±10.8 years (from 28 to 62 years). One patient was followed up for 18 years. Data of that patient were presented as a clinical case report.Results    From October, 2003 through October, 2007, 15 DCMP patients received mesh implants. Cases of in-hospital death were absent. In 3 mos. after the surgery, left ventricular volumes decreased (end-diastolic volume decreased from 251.7±80.7 to 229.0±61.3 ml; end-systolic volume decreased from 182.3±73.6 to 167.7±46.2 ml), and the left ventricular pump function improved (ejection fraction increased from 25.2±6.0 to 27.1±5.1 %; cardiac index increased from 2.0±0.5 to 2.4±0.7 ml /min /m2). The functional state of patients improved by one NYHA class, from 3.7±0.3 to 2.8±0.6. In some cases, the left ventricular size and the systolic function completely normalized. There were no episodes of circulatory decompensation in the long term after surgery. Actuarial survival for the observation period was 100%.Conclusion    Implantation of extracardiac mesh prevented progression of heart dilatation and, in combination with drug therapy, it may represent an effective method for treatment of DCMP.

Effect of 24-hour blood pressure and heart rate on the prognosis of patients with reduced and midrange LVEF

Aim    Optimal combination therapy for chronic heart failure (CHF) currently implies the mandatory use of at least four classes of drugs: renin-angiotensin-aldosterone (RAAS) system inhibitors or angiotensin receptor blocker neprilysin inhibitors (ARNI); beta-adrenoblockers (BAB); mineralocorticoid receptor antagonists; and sodium-glucose cotransporter 2 inhibitors. Furthermore, many of these drugs are able to decrease blood pressure even to hypotension and alleviate tachycardia. This study focused on the relationship of 24-h blood pressure (BP) and heart rate (HR) with the prognosis for CHF patients with sinus rhythm and left ventricular ejection fraction (LV EF) &lt;50 % as well as on suggesting possible variants of safe therapy for CHF depending on the combination of studied factors.Material and methods    Effects of clinical data, echocardiographic parameters, 24-h BP, and heart rhythm (data from 24-h BP and ECG monitors) on the prognosis of 155 patients with clinically pronounced CHF, LV EF &lt;50 %, and sinus rhythm who were followed up for 5 years after discharge from the hospital.Results    The one-factor analysis showed that the prognosis of CHF patients was statistically significantly influenced by the more severe functional class (FC) III CHF compared to FC II, reduced LV EF (&lt;35 %), a lower 24-h systolic BP (SBP) (&lt;103 mm Hg), the absence of hypotensive episodes in daytime, a low variability of nighttime BP (&lt;7.5 mm Hg), a higher 24-h HR (&gt;71 bpm vs. &lt;60 bpm), the absence of therapy with RAAS inhibitors + BAB, and a lower body weight index. The multi-factor analysis showed that more severe CHF FC, lower LV EF, and the absence of RAAS inhibitors + BAB therapy retained the influence on the prognosis. After eliminating the influencing factor of drug therapy, also a low SBP variability significantly influenced the prognosis. An additional analysis determined the following four groups of CHF patients with reduced heart systolic function according to mean 24-h HR and SBP: the largest group (38.1 % of all patients) with controlled HR (≤69 bpm), preserved SBP (&gt;103 mm Hg), and the lowest death rate of 15.3 %; the group with increased HR (&gt;69 bpm) but preserved SBP (30.3 % of all patients) where the death rate was 44.7 %, which was significantly higher than in the first group; the group with normal HR (≤69 bpm) but reduced SBP (≤103 mm Hg) (16.1 % of patients) where the death rate was 40 %, which was comparable with the second group and significantly worse than in the first group; and the group with both increased HR (&gt;69 bpm) and reduced SBP (≤103 mm Hg) (15.5 % of patients), which resulted in the maximal risk of death (70.8 % of patients with CHF and LV EF &lt;50 %), which was significantly higher than in the three other groups.Conclusion    Low SBP (including 24-h SBP with reduced variability in day- and nighttime) in combination with high HR (including by data of Holter monitoring), low LV EF, more severe clinical course of CHF, and the absence of an adequate treatment with neurohormonal modulators (RAAS inhibitors and BAB) significantly increased the risk of death. Isolating four types of FC II-III CHF with sinus rhythm and EF &lt;50% based on the combination of HR and BP identifies patients with an unfavorable prognosis, which will help developing differentiated therapeutic approaches taking into account clinical features.

The ability of modern therapy to improve the prognosis of patients with HF: role of angiotensin neprilysin inhibitors and sodium-glucose cotransporter inhibitors

Major principles for treatment of chronic heart failure with reduced left ventricular ejection fraction &lt;40% (HFrEF) include a "triple neurohormonal blockade" as a main approach. However, in recent 6 years, two new classes of drugs for the treatment of HFrEF have appeared, which beneficially influence the prognosis. These drugs are angiotensin receptor neprilysin inhibitors (ARNI) and type 2 sodium-glucose cotransporter 2 (SGLT2) inhibitors.Aim    To compare the net effect of simultaneous treatment with ARNI and SGLT2 inhibitors with the triple neurohormonal blockade in stable or decompensated patients with CHF based on Russian data.Material and methods    We analyzed the risk of death per 100 patient-years in patients with HFrEF. Stable patients were followed up at the A.L. Myasnikov Institute of Cardiology (presently, A.L. Myasnikov Research Institute of Clinical Cardiology of the National Medical Research Center of Cardiology) from 2006 through 2007; data from the EPOCH-Decompensation-CHF study were used for decompensated patients (12.2 % and 36.8 %, respectively).Results    When patients with stable HFrEF were successively switched from renin-angiotensin-aldosterone system (RAAS) inhibitors to ARNI (-16 %) and subsequently supplemented with SGLT2 (-13 %) the risk of death per 100 patient-years decreased from 12.2 % to 8.9 % (total risk decreased by 27 %; to save one patient the ARNI+ SGLT2 combination has to be prescribed to 30 patients). The estimated risk of death upon discharge from the hospital for the patients with decompensated CHF switched from RAAS inhibitors to ARNI (-16 %) and subsequently supplemented with SGLT2 (-13 %) was 26.9 deaths per 100 patient-years, whereas the number of patients to be treated for saving one life was only 10. Based on available data that demonstrate a greater effect of ARNI+ SGLT2 in patients immediately after CHF aggravation, the risk of death was recalculated. According to this analysis, the death rate per 1000 patient-years decreased from 36.8 to 19.9 % (relative risk decrease, 46 %), and to save one life only 6 patients had to be treated after they have achieved compensation of HFrEF.Conclusions    This analysis shows the importance of early initiation of the ARNI+ SGLT2 therapy in patients with both decompensated and with stable HFrEF.

[Expert consensus regarding treatment of iron deficiency in stable and decompensated patients with heart failure]

In recent years there has been significant interest in treating iron deficiency (ID) in patients with heart failure (HF) due to its high prevalence and detrimental effects in this population. As stated in the 2020 Russain HF guidelines, Intravenous ferric carboxymaltose remains the only proven therapy for ID.This document was prompted by the results from the recent AFFIRM-AHF trial which demonstrates that treatment of ID after acute HF decompensation reduces the risk of future decompensations. Experts have concluded that in HF patients with acute decompensation, a left ventricular ejection fraction of &lt; 50% and ID, Intravenous ferric carboxymaltose reduces future HF hospitalisations. Patients with stable HF may also benefit from treatment of ID to improve quality of life and alleviate symptoms.  It is, therefore, reasonable to screen for and treat ID in patients with HF.

Chronic heart failure in the Russian Federation: what has changed over 20 years of follow-up? Results of the EPOCH-CHF study

Aim    To study the etiology and the dynamics of prevalence and mortality of CHF; to evaluate the treatment coverage of such patients in a representative sample of the European part of the Russian Federation for a 20-year period. Material and methods    A representative sample of the European part of the Russian Federation followed up for 2002 through 2017 (n=19 276); a representative sample of the population of the Nizhny Novgorod region examined in 1998 (n=1922).Results    During the observation period since 2002, the incidence of major CHF symptoms (tachycardia, edema, shortness of breath, weakness) tended to decrease while the prevalence of cardiovascular diseases has statistically significantly increased. During the period from 1998 through 2017, the prevalence of I-IV functional class (FC) CHF increased from 6.1 % to 8.2 % whereas III-IV FC CHF increased from 1.8 % to 3.1 %. The main causes for the development of CHF remained arterial hypertension and ischemic heart disease; the role of myocardial infarction and diabetes mellitus as causes for CHF was noted. For the analyzed period, the number of treatment components and the coverage of basic therapy for patients with CHF increased, which probably accounts for a slower increase in the disease prevalence by 2007-2017. The prognosis of patients was unfavorable: in I-II FC CHF, the median survival was 8.4 (95 % CI: 7.8-9.1) years and in III-IV FC CHF, the median survival was 3.8 (95 % CI: 3.4-4.2) years.

Hydroxychloroquine in patients with novel coronavirus infection (COVID-19): a case-control study

Actuality One of the most widely discussed treatments for patients with COVID-19, especially at the beginning of the epidemy, was the use of the antimalarial drug hydroxychloroquine (HCQ). The first small non-randomized trials showed the ability of HCQ and its combination with azithromycin to accelerate the elimination of the virus and ease the acute phase of the disease. Later, large, randomized trials did not confirm it (RECOVERY, SOLIDARITY). This study is a case-control study in which we compared patients who received and did not receive HCQ.Material and Methods 103 patients (25 in the HCQ treatment group and 78 in the control group) with confirmed COVID-19 (SARS-CoV-2 virus RNA was detected in 26 of 73 in the control group (35.6%) and in 10 of 25 (40%) in the HCQ group) and in the rest - a typical picture of viral pneumonia on multislice computed tomography [MSCT]) were included in the analysis. The severity of lung damage was limited to stages I-II, the CRP level should not exceed 60 mg/dL, and oxygen saturation in the air within 92-98%. We planned to analysis the duration of treatment of patients in the hospital, the days until the normalization of body temperature, the number of points according to the original SHOCS-COVID integral scale, and changes in its components (C-reactive protein (CRP), D-dimer, and the percentage of lung damage according to MSCT).Results Analysis for the whole group revealed a statistically significant increase in the time to normalization of body temperature from 4 to 7 days (by 3 days, p&lt;0.001), and the duration of hospitalization from 9.4 to 11.8 days (by 2.4 days, p=0.002) when using HCQ in comparison with control. Given the incomplete balance of the groups, the main analysis included 46 patients who were matched by propensity score matching. The trend towards similar dynamics continued. HCQ treatment slowed down the time to normalization of body temperature by 1.8 days (p=0.074) and lengthened the hospitalization time by 2.1 days (p=0.042). The decrease in scores on the SHOCS -COVID scale was statistically significant in both groups, and there were no differences between them (delta - 3.00 (2.90) in the HCQ group and - 2.69 (1.55) in control, p=0.718). At the same time, in the control group, the CRP level returned to normal (4.06 mg/dl), and with the use of GC, it decreased but remained above the norm (6.21 mg/dl, p=0.05). Side effects requiring discontinuation of treatment were reported in 3 patients in the HCQ group and none in the control group.Conclusion We have not identified any positive properties of HCQ and its ability to influence the severity of COVID-19. This antimalarial agent slows down the normalization of the body's inflammatory response and lengthens the time spent in the hospital. HCQ should not be used in the treatment of COVID-19.

Proactive anti-inflammatory therapy with colchicine in the treatment of advanced stages of new coronavirus infection. The first results of the COLORIT study

Actuality The course of the novel coronavirus disease (COVID-19) is unpredictable. It manifests in some cases as increasing inflammation to even the onset of a cytokine storm and irreversible progression of acute respiratory syndrome, which is associated with the risk of death in patients. Thus, proactive anti-inflammatory therapy remains an open serious question in patients with COVID-19 and pneumonia, who still have signs of inflammation on days 7-9 of the disease: elevated C-reactive protein (CRP)&gt;60 mg/dL and at least two of the four clinical signs: fever &gt;37.5°C; persistent cough; dyspnea (RR &gt;20 brpm) and/or reduced oxygen blood saturation &lt;94% when breathing atmospheric air. We designed the randomized trial: COLchicine versus Ruxolitinib and Secukinumab in Open-label Prospective Randomized Trial in Patients with COVID-19 (COLORIT). We present here data comparing patients who received colchicine with those who did not receive specific anti-inflammatory therapy. Results of the comparison of colchicine, ruxolitinib, and secukinumab will be presented later.Objective Compare efficacy and safety of colchicine compared to the management of patients with COVID-19 without specific anti-inflammatory therapy.Material and Methods Initially, 20 people were expected to be randomized in the control group. However, enrollment to the control group was discontinued subsequently after the inclusion of 5 patients due to the risk of severe deterioration in the absence of anti-inflammatory treatment. Therefore, 17 patients, who had not received anti-inflammatory therapy when treated in the MSU Medical Research and Educational Center before the study, were also included in the control group. The effects were assessed on day 12 after the inclusion or at discharge if it occurred earlier than on day 12. The primary endpoint was the changes in the SHOCS-COVID score, which includes the assessment of the patient's clinical condition, CT score of the lung tissue damage, the severity of systemic inflammation (CRP changes), and the risk of thrombotic complications (D-dimer) [1].Results The median SHOCS score decreased from 8 to 2 (p = 0.017), i.e., from moderate to mild degree, in the colchicine group. The change in the SHOCS-COVID score was minimal and statistically insignificant in the control group. In patients with COVID-19 treated with colchicine, the CRP levels decreased rapidly and normalized (from 99.4 to 4.2 mg/dL, p&lt;0.001). In the control group, the CRP levels decreased moderately and statistically insignificantly and achieved 22.8 mg/dL by the end of the follow-up period, which was still more than four times higher than normal. The most informative criterion for inflammation lymphocyte-to-C-reactive protein ratio (LCR) increased in the colchicine group by 393 versus 54 in the control group (p = 0.003). After treatment, it was 60.8 in the control group, which was less than 100 considered safe in terms of systemic inflammation progression. The difference from 427 in the colchicine group was highly significant (p = 0.003).The marked and rapid decrease in the inflammation factors was accompanied in the colchicine group by the reduced need for oxygen support from 14 (66.7%) to 2 (9.5%). In the control group, the number of patients without anti-inflammatory therapy requiring oxygen support remained unchanged at 50%. There was a trend to shorter hospital stays in the group of specific anti-inflammatory therapy up to 13 days compared to 17.5 days in the control group (p = 0.079). Moreover, two patients died in the control group, and there were no fatal cases in the colchicine group. In the colchicine group, one patient had deep vein thrombosis with D-dimer elevated to 5.99 µg/mL, which resolved before discharge.Conclusions Colchicine 1 mg for 1-3 days followed by 0.5 mg/day for 14 days is effective as a proactive anti-inflammatory therapy in hospitalized patients with COVID-19 and viral pneumonia. The management of such patients without proactive anti-inflammatory therapy is likely to be unreasonable and may worsen the course of COVID-19. However, the findings should be treated with caution, given the small size of the trial.

[The role of diastolic transthoracic stress echocardiography with incremental workload in the evaluation of heart failure with preserved ejection fraction: indications, methodology, interpretation. Expert consensus developed under the auspices of the National Medical Research Center of Cardiology, Society of Experts in Heart Failure (SEHF), and Russian Association of Experts in Ultrasound Diagnosis in Medicine (REUDM)]

Diagnosis of heart failure with preserved ejection fraction (HFpEF) is associated with certain difficulties since many patients with HFpEF have a slight left ventricular diastolic dysfunction and normal filling pressure at rest. Diagnosis of HFpEF is improved by using diastolic transthoracic stress-echocardiography with dosed exercise (or diastolic stress test), which allows detection of increased filling pressure during the exercise. The present expert consensus explains the requirement for using the diastolic stress test in diagnosing HFpEF from clinical and pathophysiological standpoints; defines indications for the test with a description of its methodological aspects; and addresses issues of using the test in special patient groups.

[The use of diuretics in chronic heart failure. Position paper of the Russian Heart Failure Society]

The document focuses on key issues of diuretic therapy in CHF from the standpoint of current views on the pathogenesis of edema syndrome, its diagnosis, and characteristics of using diuretics in various clinical situations.

[How evaluate results of treatment in patients with COVID-19? Symptomatic Hospital and Outpatient Clinical Scale for COVID-19 (SHOCS-COVID)]

Aim Development of a novel scale for assessing medical state in patients with new coronavirus infection based on clinical and laboratory disease severity's markers, named SHOKS-COVID scale.Material and Methods Clinical Assessment Scale (SHOKS-COVID) is based on1: clinical parameters (respiratory rate, Body temperature, SpO2 need and type of ventilation support) 2: Inflammation markers (C reactive protein (CRP) and prothrombotic marker (D-dimer)) and 3: percent of lungs injury by CT. This scale was used in several clinical studies in patients with varying severity of the course of the COVID 19. SHOKS-COVID scale was also compared against some additional biomarkers and with length of hospital stay.Results In patients with severe COVID-19 (Clinical Trial WAYFARER - 34 patients), SHOKS-COVID scores were correlated with the degree of inflammation: CRP (r = 0.64; p &lt;0.0001); the ratio lymphocytes / CRP (r = - 0.64; p &lt;0.0001). Also, SHOKS-COVID score correlated with the D-dimer (r = 0.35; p &lt;0.0001) and percentage lung damage on multispiral computed tomography (MSCT) - (r = 0.77, p &lt; 0.0001) and length stay in the clinic (r = 0.57, p = 0.0009). In patients with mild course (BISQUIT Study - 103 patients), SHOKS-COVID scores had a statistically significant positive correlation with length of fever (r = 0.37; p = 0.0002) and length of stay in the clinic (r = 0.52, p &lt;0.0001) and negatively correlated with the ratio of lymphocytes / CRP (-0.78, p &lt;0.0001) and the level of CRP (r=0.78; p &lt;0.0001). Patents were grouped based on severity of COVID 19 and median and interquartile range (IQR) of SHOCKS-COVID were measured in these groups. Median and IQR of SHOCKS-COVID were 2.00 [1.0-2.5] points in mild course, 4.0 points [3.0-5.0] in moderate course, 7.0 points [6.0-9.0] in moderately severe course,12.0 points [10.0-14.0] in severe course of disease and 15.0 points [14.5-15.5] in extremely severe patients.Conclusion Here we report a novel scale of COVID 19 disease progression. This scale ranges from zero in asymptomatic patients (with normal range of biomarkers and without lung damage on CT) to fifteen in extremely severe patients. The scores for SHOKS-COVID are increasing, in parallel with the deterioration of all other biomarkers of severity and prognosis in patients with new coronavirus infection. Based on the analysis carried out, we were able to determine values of SHOKS-COVID scale and levels of main clinical and laboratory markers in patients with different severity of COVID 19.

[Results of Open-Label non-Randomized Comparative Clinical Trial: "BromhexIne and Spironolactone for CoronаvirUs Infection requiring hospiTalization (BISCUIT)]

Introduction The aim of this study was to assess the efficacy and safety of a combination of bromhexine at a dose of 8 mg 4 times a day and spironolactone 50 mg per day in patients with mild and moderate COVID 19.Material and methods It was an open, prospective comparative non-randomized study. 103 patients were included (33 in the bromhexine and spironolactone group and 70 in the control group). All patients had a confirmed 2019 novel coronavirus infection (COVID 19) based on a positive polymerase chain reaction (PCR) for SARS-CoV-2 virus RNA and/or a typical pattern of viral pneumonia on multispiral computed tomography. The severity of lung damage was limited to stage I-II, the level of CRP should not exceed 60 mg / dL and SO2 in the air within 92-98%. The duration of treatment is 10 days.Results The decrease in scores on the SHOKS-COVID scale, which, in addition to assessing the clinical status, the dynamics of CRP (a marker of inflammation), D-dimer (a marker of thrombus formation), and the degree of lung damage on CT (primary endpoint) was statistically significant in both groups and differences between them was not identified. Analysis for the group as a whole revealed a statistically significant reduction in hospitalization time from 10.4 to 9.0 days (by 1.5 days, p=0.033) and fever time from 6.5 to 3.9 days (by 2.5 days, p&lt;0.001). Given the incomplete balance of the groups, the main analysis included 66 patients who were match with using propensity score matching. In matched patients, temperature normalization in the bromhexine/spironolactone group occurred 2 days faster than in the control group (p=0.008). Virus elimination by the 10th day was recorded in all patients in the bromhexine/spironolactone group; the control group viremia continued in 23.3% (p=0.077). The number of patients who had a positive PCR to the SARS-CoV-2 virus on the 10th day of hospitalization or longer (≥10 days) hospitalization in the control group was 20/21 (95.2%), and in the group with bromhexine /spironolactone -14/24 (58.3%), p=0.012. The odds ratio of having a positive PCR or more than ten days of hospitalization was 0.07 (95% CI: 0.008 - 0.61, p=0.0161) with bromhexine and spironolactone versus controls. No side effects were reported in the study group.Conclusion The combination of bromhexine with spironolactone appeared effective in treating a new coronavirus infection by achieving a faster normalization of the clinical condition, lowering the temperature one and a half times faster, and reducing explanatory combine endpoint the viral load or long duration of hospitalization (≥ 10 days).

[Proactive anti-inflammatory and anticoagulant therapy in the treatment of advanced stages of novel coronavirus infection (COVID-19). Case Series and Study Design: COLchicine versus ruxolitinib and secukinumab in open prospective randomIzed trial (COLORIT)]

The article is devoted to the treatment of the new coronavirus infection (COVID-19) in the advanced stages of the disease. The types of response of the immune system to the viral load of SARS-CoV-2 with the start of the inflammation process are considered. The situation is analyzed in detail in which the growing autoimmune inflammation (up to the development of a "cytokine storm") affects not only the pulmonary parenchyma, but also the endothelium of the small vessels of the lungs. Simultaneous damage to the alveoli and microthrombosis of the pulmonary vessels are accompanied by a progressive impairment of gas exchange, the development of acute respiratory distress syndrome, the treatment of which, even with the use of invasive ventilation, is ineffective and does not really change the prognosis of patients with COVID-19. In order to interrupt the pathological process at the earliest stages of the disease, the necessity of proactive anti-inflammatory therapy in combination with active anticoagulation treatment is substantiated. The results of the first randomized studies on the use of inhibitors of pro-inflammatory cytokines and chemokines (interleukin-6 (tocilizumab), interleukin-17 (secukinumab), Janus kinase blockers, through which the signal is transmitted to cells (ruxolitinib)), which have potential in the early treatment of COVID- 19. The use of a well-known anti-inflammatory drug colchicine (which is used for gout treatment) in patients with COVID-19 is considered. The design of the original COLORIT comparative study on the use of colchicine, ruxolitinib and secukinumab in the treatment of COVID-19 is presented. Clinical series presented, illustrated early anti-inflammatory therapy together with anticoagulants in patients with COVID-19 and the dangers associated with refusing to initiate such therapy on time.

[Combination therapy at an early stage of the novel coronavirus infection (COVID-19). Case series and design of the clinical trial "BromhexIne and Spironolactone for CoronаvirUs Infection requiring hospiTalization (BISCUIT)"]

The article focuses on effective treatment of the novel coronavirus infection (COVID-19) at early stages and substantiates the requirement for antiviral therapy and for decreasing the viral load to prevent the infection progression. The absence of a specific antiviral therapy for the SARS-CoV-2 virus is stated. The authors analyzed results of early randomized studies using lopinavir/ritonavir, remdesivir, and favipiravir in COVID-19 and their potential for the treatment of novel coronavirus infection. Among the drugs blocking the virus entry into cells, the greatest attention was paid to the antimalaria drugs, chloroquine and hydroxychloroquine. The article addresses in detail ineffectiveness and potential danger of hydroxychloroquine, which demonstrated neither a decrease in the time of clinical recovery nor any improvement of prognosis for patients with COVID-19. The major objective was substantiating a possible use of bromhexine, a mucolytic and anticough drug, which can inhibit transmembrane serin protease 2 required for entry of the SARS-CoV-2 virus into cells. Spironolactone may have a similar feature. Due to its antiandrogenic effects, spironolactone can inhibit X-chromosome-related synthesis of ACE-2 receptors and activation of transmembrane serin protease 2. In addition to slowing the virus entry into cells, spironolactone decreases severity of fibrosis in different organs, including the lungs. The major part of the article addresses clinical examples of managing patients with COVID-19 at the University Clinic of the Medical Research and Educational Centre of the M. V. Lomonosov Moscow State University, including successful treatment with schemes containing bromhexine and spironolactone. In conclusion, the authors described the design of a randomized, prospective BISCUIT study performed at the University Clinic of the M. V. Lomonosov Moscow State University with an objective of evaluating the efficacy of this scheme.

[Steroid pulse -therapy in patients With coronAvirus Pneumonia (COVID-19), sYstemic inFlammation And Risk of vEnous thRombosis and thromboembolism (WAYFARER Study)]

Introduction Coronavirus pneumonia not only severely affects the lung tissue but is also associated with systemic autoimmune inflammation, rapid overactivation of cytokines and chemokines known as "cytokine storm", and a high risk of thrombosis and thromboembolism. Since there is no specific therapy for this new coronavirus infection (COVID-19), searching for an effective and safe anti-inflammatory therapy is critical.Materials and methods This study evaluated efficacy and safety of pulse therapy with high doses of glucocorticosteroids (GCS), methylprednisolone 1,000 mg for 3 days plus dexamethasone 8 mg for another 3-5 days, in 17 patients with severe coronavirus pneumonia as a part of retrospective comparative analysis (17 patients in control group). The study primary endpoint was the aggregate dynamics of patients' condition as evaluated by an original CCS-COVID scale, which included, in addition to the clinical status, assessments of changes in the inflammation marker, C-reactive protein (CRP); the thrombus formation marker, D-dimer; and the extent of lung injury evaluated by computed tomography (CT). Patients had signs of lung injury (53.2 % and 25.6 %), increases in CRP 27 and 19 times, and a more than doubled level of D-dimer (to 1.41 µg/ml and 1.15 µg/ml) in the active therapy and the control groups, respectively. The GCS treatment group had a more severe condition at baseline.Results The GCS pulse therapy proved effective and significantly decreased the CCS-COVID scores. Median score difference was 5.00 compared to the control group (р=0.011). Shortness of breath considerably decreased; oxygen saturation increased, and the NEWS-2 clinical status scale scores decreased. In the GCS group, concentration of CRP significantly decreased from 134 mg/dl to 41.8 mg/dl (р=0.009) but at the same time, D-dimer level significantly increased from 1.41 µg/ml to 1.98 µg/ml (р=0.044). In the control group, the changes were nonsignificant. The dynamics of lung injury by CT was better in the treatment group but the difference did not reach a statistical significance (р=0.062). Following the GCS treatment, neutrophilia increased (р=0.0001) with persisting lymphopenia, and the neutrophil/lymphocyte (N/L) ratio, a marker of chronic inflammation, increased 2.5 times (р=0.006). The changes in the N/L ratio and D-dimer were found to correlate in the GCS pulse therapy group (r =0.49, p=0.04), which underlined the relationship of chronic autoimmune inflammation with thrombus formation in COVID-19. No significant changes were observed in the control group. In result, four patients developed venous thromboembolic complications (two of them had pulmonary artery thromboembolism) after the GCS pulse therapy despite the concomitant antiplatelet treatment at therapeutic doses. Recovery was slower in the hormone treatment group (median stay in the hospital was 26 days vs 18 days in the control group, р=0.001).Conclusion Pulse therapy with high doses of GCS exerted a rapid anti-inflammatory effect but at the same time, increased the N/L ratio and the D-dimer level, which increased the risk of thromboembolism.

[Modification of the of the cardiometabolic profile using combined therapy of the angiotensin receptor-neprilysin inhibitor and empagliflozin in comorbid patients with Chronic Heart Failure and type 2 Diabetes Mellitus]

Chronic heart failure (CHF) and type 2 diabetes mellitus (DM2) and very common comorbidities with bidirectional, mutually aggravating courses. DM2 is known as an independent risk factor of cardiovascular complications whereas a higher CHF functional class is associated with increased risk of DM2. At present time, hypoglycemic drugs of the gliflozin class and the angiotensin receptor-neprilysin inhibitor (ARNI) are widely discussed in connection with their use in the treatment of patients with CHF and DM. The PARADIGM-HF study investigated effects of long-term treatment of CHF with reduced ejection fraction with presently the only representative of the ARNI class, a single supramolecular complex of valsartan-sacubitril. This medicine has already exceled enalapril at the effect not only on the incidence of nonfatal and fatal cardiovascular events but also on general mortality. Mean age of patients included into that study was 63.8±11.5 years; 21 % of them were females. In real-life clinical practice, physicians more frequently see older patients, and most of them are females, particularly with DM2. On the other hand, sodium-glucose cotransporter-2 inhibitors, including empagliflozin, significantly decreased the death rate and the frequency of CHF exacerbations in patients with DM2 and concomitant cardiovascular diseases, including CHF. This article describes a clinical case of initiating the valsartan-sacubitril treatment in combination with empagliflozin in an elderly female patient with congestive CHF with intermediate ejection fraction (EF) and comorbidities, including a history of myocardial infarction and DM2. Of interest is the rapid positive dynamics of clinical, laboratory (NT-proBNP) and instrumental (echocardiography) markers of CHF. At 3 months, the EF "recovered" from intermediate to preserved during the use of a comprehensive cardio-reno-metabolic approach. Both cardiologists and endocrinologists should definitely consider this approach in managing such patients since current cardiological drugs have additional pleiotropic metabolic effects whereas hypoglycemic drugs, in their turn, influence the cardiological prognosis.

[Therapeutic approaches to the Rational Use of trip-le combination therapy with a fixed combination of amlodipine, indapamide and perindopril arginine (TRIPLE COMBINATION) in patients with hypertension who do not control blood pressure on conventional treatment. (Description and main results of the TRIO program)]

Aim To study tactics of outpatient physicians in choosing the treatment when the previous double antihypertensive therapy (AHT) fails and to analyze the effectivity of an amlodipine/indapamide/perindopril arginine triple combination (TC).Material and methods The program included 1252 patients with arterial hypertension (AH); the TC group consisted of 992 (79.23 %) patients (38.3 % males; age, 61.6 [55.0; 67.9]); the control group included 260 (20.77 %) patients (37.7 % males; age, 60.6 [53.3; 67.4]). The main inclusion criteria were essential AH, age 18-79 years, insufficient response to previous AHT (clinical systolic blood pressure (SBP) &gt;140-179 mm Hg). The study duration was three months. The following parameters were evaluated: dynamics of clinical and ambulatory BP (BP self-monitoring (BPSM); frequency of achieving the first goal of &lt;140 / 90 mm Hg and the goal of &lt;130 / 80 mm Hg); and changes in glomerular filtration rate (GFR) and quality of life (QoL). Responses to TC were analyzed in groups with different ranges of increased baseline SBP in patients with AH and diabetes mellitus (DM)/impaired glucose tolerance (IGT), overweight or obesity, and chronic kidney disease (CKD, reduced estimated GFR (eGFR &lt;60 ml/min/1.73 m2). Safety was evaluated based on records of adverse events (AEs).Results The TC group had a more severe condition at baseline by clinical parameters and history and had higher baseline BP, which made difficult the intergroup comparison. Nevertheless at three months, the decrease in clinical SBP was more pronounced in the TC group (from 162.1  to 126.8 mm Hg, Δ=35.7  mm Hg) than in the control group (from 157.8 to 128.4  mm Hg, Δ=29.4  mm Hg). 87.8% of patients in the TC group and 81.9 % (р=0.012) in the control group achieved the first BP goal of &lt;140 / 90 mm Hg; 34.3% and 28.2% of patients, respectively, achieved the BP goal of &lt;130 / 80 mm Hg (р=0.055). The more effective SBP control in the TC group was associated with a pronounced BP decrease with higher BP values at baseline, which was also confirmed by an analysis in subgroups with SBP 140-160, 160-180, and &gt;180 mm Hg. The TC treatment was associated with a pronounced antihypertensive effect with respect of BPSM values, improved QoL, and renal function. Significant decreases in BP and achievement of BP goals by a vast majority of patients receiving TC were also observed in subgroups with DM or IGT, overweight and/or obesity, and CKD. AEs were observed during the treatment only in 8 patients (0.64 %), which confirmed good tolerability and high safety of the therapy.Conclusion The study results demonstrated a therapeutic effect of the amlodipine/indapamide/perindopril arginine fixed-dose combination (Triplixam®). This effect was evident as control of clinical BP with any baseline BP level, including different ranges of increased SBP, in AH combined with DM, IGT, obesity, and CKD, which offers advantages over a subjective choice of AHT. TC improved BPSM values, QoL indexes, provided nephroprotection, and was well tolerated.

[Position Paper. The role of iron deficiency in patients with chronic heart failure and current corrective approaches]

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[Difficulties in diagnosis of heart failure with preserved ejection fraction in clinical practice: dissonance between echocardiography, NTproBNP and H2HFPEF score]

This pilot study was aimed to assess the percentage of patients admitted to a Russian hospital and diagnosed with heart failure with preserved ejection fraction (HFpEF) maintaining this diagnosis when evaluated against the ESC 2016 and Russian 2017 heart failure guidelines. In addition, we reviewed the probability of an HFpEF diagnosis when patients were assessed against the H2FPEF score. Forty-two patients (mean age 68 ±7,5) diagnosed with HFpEF on their discharge record, admitted between March 2018 and May 2018, were included. Twenty percent of patients did not meet Russian guideline criteria for HFpEF due to either the absence of symptoms and/or echocardiographic evidence of structural/functional abnormalities. Using the ESC 2016 guidelines (which required an elevation in NT Pro BNP) the diagnosis was confirmed in only 37% of patients, mostly due to the normal level of NTproBNP in 54.8% of those investigated. The probability of HFpEF by H2FPEF score in patients with dyspnea and HFpEF by ESC 2016 criteria was 93% and without HFpEF by ESC 2016 criteria 68% (p = 0.054). In contrast, the probability of HFpEF by H2FPEF score in patients with dyspnea and HFpEF by Russian criteria was 84.4%.

[Possibilities of clinical use of ezetimibe Otrio (JSC "AKRIKHIN", Russia) in patients with high and very high cardiovascular risk who have not reached the target values of lipid metabolism. Conclusion of the Board of experts]

This Conclusion of the Board of experts is devoted to the analysis of the evidence base, the position in modern clinical guidelines, the efficacy and safety analysis as well as the options of combined therapy with statins and ezetimibe (Otrio, JSC "AKRIKHIN") in various categories of patients in routine clinical practice in theRussian Federation. Cardiovascular diseases (CVD) continue to lead in the structure of morbidity and mortality inRussia. Hypercholesterolemia is one of the main modifiable risk factors for CVD. Administration of HMGCo-A-reductase inhibitors (statins) remains the basis for the prevention and treatment of the main complications of atherosclerosis, but the achievement of target levels of LDL-C on of statin monotherapy in Russian practice among different categories of risk does not exceed 50%. Proportion of patients (up to 12%) does not tolerate statin therapy, which requires the search for alternative therapies. To optimize the control of the level of LDL-C, combination therapy with statins and ezetimibe is used. Ezetimibe is an effective lipid-lowering drug, an inhibitor of intestinal absorption of cholesterol, which was investigated in many international and Russian studies, the results of which have demonstrated good tolerability, safety and efficacy (reduction of LDL-C levels by 18% in monotherapy). It was noted that the combined therapy with low/medium doses of statins and ezetimibe effectively reduces the level of LDL-C by 44-53%, which is comparable to the effect of high doses of statins and reduces CV risk in patients with CKD and ACS. Otrio (INN Ezetimib) tablets 10 mg ( JSC "AKRIKHIN",Russia) has demonstrated bioequivalence to the original drug Ezetrol tablets 10 mg (Schering-plough Labo N. V,Belgium). Broad use of a new generic product Otrio in combination with different statins will significantly increase the frequency of achievement of target lipid levels in patients with high and very high CV risk, including patients with chronic renal failure, type 2 diabetes and in patients with high hypercholesterolemia (LDL-C &gt; 5 mmol/l) and, ultimately, reduce the burden of CV disease and mortality in Russia.

EPOCHA-AH 1998–2017. Dynamics of prevalence, awareness of arterial hypertension, treatment coverage, and effective control of blood pressure in the European part of the Russian Federation

AIM

To perform a repeated epidemiological study of a representative sample in the European part of the Russian Federation in 2017 and to compare the dynamics of arterial hypertension (AH) prevalence with the effectiveness of blood pressure (BP) control in the population compared to 1998, 2002, and 2007.

MATERIALS AND METHODS

A representative sample of the European part of the Russian Federation was created in 2002 and re-examined in 2007 and 2017. In 1998, a pilot project was performed for examining a representative sample for the Nizhniy Novgorod region.

RESULTS

During 19 years of follow-up, the AH prevalence increased from 35.5 to 43.3%. Te awareness and treatment coverage reached 76.9 and 79.3%, respectively, in 2017. Achievement of the target BP with a single measurement also increased among patients receiving antihypertensive medication from 14.3 to 34.9%. For the treatment of AH, medium-acting antihypertensive drugs are used, ofen at suboptimal doses.

CONCLUSION

Epidemiological indices of awareness, treatment coverage, and number of effectively managed patients with AH have improved. However, the AH prevalence has increased by 7.8% for 19 years, which indicates inefciency of the primary prevention of this disease.

Characteristics and treatment of patients with heart failure admitted to a cardiology department in 2002 and 2016

AIM

To investigate the difference in characteristics of patients admitted to the Tomsk National Research Medical Center with a diagnosis of heart failure (HF) in 2002 and 2016.

METHODS

Medical charts of all patients hospitalised in a single centre, with a diagnosis of HF, were included. Two three‑month periods were compared from January 2002 (n=210) and January 2016 (n=378).

RESULTS

Fewer patients with HF had symptoms or required diuretics in 2016 (63 % vs 98,6 %, p&lt;0.001). During this period the percentage of patients with HFpEF increased from 58.6 % to 74.1 % (p=0.001) whereas those with HFrEF remained similar (19.5 % vs 14.0 %, p=0.1) and those with HFmrEF declined (21.9 % vs 11,9 %, p=0.007). In patients with HFrEF the prescription of ACEi / ARB remained similar (80.4 vs 88 %, p=0.3), beta‑blockers increased from 68 to 85 % (p=0.03) and aldosterone antagonists from 9.7 to 49 % (p&lt;0.001).

CONCLUSION

Prescription rates for prognostic medications in HFrEF improved in 2016. The substantial percentage of patients diagnosed with HFpEF without symptoms or diuretic raises the question of whether a diagnosis of HF was appropriate in some cases.

Features of diagnostics and treatment of chronic heart failure in elderly and senile patients. Expert opinion of the Society of Experts in Heart Failure, Russian Association of Gerontologists, and Euroasian Association of Therapists

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[Anxiety and Depression in Chronic Heart Failure. What Can a Cardiologist Do?]

AIM

To reveal the probability and duration of the onset of remission of anxiety-depressive symptoms in patients with CHF III-IV receiving optimal medicine treatment (OMT) or (OMT), supplemented with the education program and active outpatient monitoring (OMT + A).

MATERIALS AND METHODS

A secondary analysis of the results of RCT CHANCE, which studied the impact of the training program and active outpatient control (further additional exposure (DV) plus optimal medication (OMT) on mortality and cardiovascular hospitalization in patients with CHF III-IV FC. Therapeutic training and outpatient control performed by the cardiologist after discharge from the hospital (weekly in the first month, every 2 weeks for the next 2 months, and then On the basis of the results of the telephone contact, an additional visit could be scheduled, the CHANCE study control group was made up of patients on OMT who were observed as practiced in regular health care setting. Control group had 4 visits to the cardiologist during the 1 year observation. The present analysis included patients on OMT and OMT + DV who had a clinically significant anxiety at the 0 week of the CHANCE program using the Hospital Anxiety and Depression Scale (HADS) (the sum of scores on the anxiety subscale ≥11), depression (the sum of scores on the depression subscale ≥11), or a combination of anxiety and depressive symptoms (scores on anxiety and depression subscales ≥11). Patients who did not pass HADS or SHOCK testing at 0.24 and 48 weeks were excluded from the analyses. A total of 237 patients were included. Severity of HF symptoms were assessed by "Scale of Heart failure Optimizing Clinical Status (SHOCS)" and compared it with the shares of patients who reached remission (HADS scores.

[Characteristics and treatment of hospitalized patients with CHF]

The article analyzes some characteristics of hospitalized patients with decompensated chronic heart failure (HF) according to data from Russian and international registries, management of decompensated HF, and tactics for titration of evidence-based disease-modified therapies. The demographic characteristics of the patients from the registers that were used for the research are similar. Yet, the proportion of HF patients with preserved LVEF was greater according to data from several Russian studies. Meanwhile, with the patients that did not receive any loop diuretics and therefore had apparently no congestion signs being excluded from the analysis, the proportion of HF patients with preserved LVEF became similar to that from the international studies. The registers also showed that pulmonary edema and acute left ventricular failure were observed in less than a half of the cases. Nevertheless, patients with mild congestion symptoms still have bad lingering prognosis and require the same amount of medical attention. Up to 40 % of admissions for decompensated CHF resulted from a dietary disorder (excessive sodium consumption), low compliance with therapy and lack of access to primary care providers. Furthermore, the analysis of the outpatient treatment administered prior to the forthcoming hospitalization showed a low prescription rate of evidence-based disease-modifying therapies (ACEi or ARNi, BB, MRA). It is emphasized that in part of patients the administration and/or titration of this therapy can be started during hospitalization. The article also discusses the use of a new class of drugs, angiotensin receptor-neprilysin inhibitors (ARNi), including not only transferring patients from ACEi to ARNi but also the possibility of administering ARNi to stable, hospitalized patients who do not require intravenous diuretics and inotropic drugs.

[Role of heart rate in mechanisms of compensation and decompensation in CHF patients with sinus rhythm and atrial fibrillation and methods for safe and efficient control of heart rhythm. Part 2. Atrial fibrillation]

This review focuses on the role of heart rate in patients with a combination of heart failure and atrial fibrillation and on methods for heart rate control in such patients.

[Methods of Prevention of Sudden Death in Chronic Heart Failure]

Chronic heart failure (CHF) is a natural finale of all cardiovascular diseases. Its prevalence in Russian Federation (as assessed using traditional Framingham criteria) is 4.5% what corresponds to 5 million patients. Prognosis of decompensation of cardiac action remains unfavorable even at the background of optimal drug therapy and use of nondrug methods of treatment. Main causes of death of patients with CHF are cardiac decompensation and sudden cardiac death (SCD). In this review, we present analysis of Russian and foreign studies which have investigated immediate causes of SCD as well as methods of its primary and secondary prevention.

Oxidative stress in patients with chronic heart failure and type 2 diabetes mellitus

Parameters of oxidative stress were studied in patients with chronic heart failure and/or type 2 diabetes mellitus. Chronic heart failure was accompanied by severe oxidative stress, while in patients with type 2 diabetes mellitus the signs of oxidative stress were less pronounced. The intensity of free radical oxidation in patients with chronic heart failure and type 2 diabetes mellitus was not higher compared to patients with chronic heart failure.

[Efficacy and safety of long-term application of spironolactone in patients with moderate and severe chronic heart failure receiving optimal therapy]

Aim of the investigation was the study of influence of spironolactone (25 - 75 mg/day) on clinico-functional status, parameters of left ventricular (LV) remodeling, as well as safety of its long term application in patients with chronic heart failure (CHF) receiving optimal therapy. Forty nine patients were included in the study - 44 men (89,8%) and 5 women (10,2%) in the age from 28 to 75 years with II-IV NYHA functional class (FC) CHF, LV ejection fraction (EF) 35%, plasma levels of creatinine 150 mmol/L and potassium 5 mmol/L. Main causes of development of CHF were dilated cardiomyopathy, ischemic heart disease (large focal postinfarction cardiosclerosis) and decompensated hypertensive heart [25/20/4 (51%/40,8%/8,2%), respectively]. As a result of randomization procedure 2 groups of observation were formed: group 1 - 19 patients receiving spironolactone in a 24 hour dose 25 - 75 mg, group 2 - control group - 30 patients without therapy with spironolactone. Inhibitors of angiotensin converting enzyme (ACE) took 100%, b-adrenoblockers - 63,2% of patients. Control examination was conducted before randomization, in 6 and 12 months of follow up. During period of observation no changes of FC were noted in control group. In the group of treatment with spironolactone after 6 months in 6 patients FC lowered ( =0,028). By the end of follow up the given effect lost its significance, but 5 (38,5%) patients by termination of the study had FC II of CHF, what was accompanied with moderate increase of distance walked during 6-minute walk test from 354 to 378 m. In patients in the group of spironolactone treatment already after 6 months of treatment there occurred decrease of LV volumes, what by the end of period of observation for LV end diastolic volume (EDV) amounted - 76 ( - 118; - 7), and for LV end systolic volume (ESV) - 53 ml ( - 96; - 7) ml ( =0,008) at absolute increment of LVEF by 3 (0; 12)% ( =0,05). In control group in 12 months decrease of LVEDV was less pronounced and LV ESV did not change. Finally after 12 months of observation the groups became to differ by change of LVEF ( =0,035) and LVESV ( =0,02). Changes of LV volumes were followed by lowering of median concentration of atrial natriuretic peptide (ANP) in plasma by - 51,9 ( - 87; - 43,9) mg/ml. At the same time in control group gradual rise of concentration of the given peptide was observed from initial 107,3 to 168,5 mg/ml at the moment of study termination. Changes of BP level, creatinine concentration in patients in the study were not fixed in any of treatment groups. Development of moderate hyperkaliemia amounted 21.0%, gynecomastia or pain in the region of mammary glands were fixed in 26,3% of patients in 12 months of treatment. Addition of spironolactone in a dose of 75 mg/day to optimal therapy, including ACE inhibitor and b-adrenoblocker is accompanied with improvement of clinical state and FC of patients with moderate and severe CHF. Long term therapy with spironolactone blocks processes of desadaptive LV remodeling and improves LV contractile function, what is reflected in lowering of ANP concentration in plasma of patients with CHF. Application of spironolactone in combination with ACE inhibitor and b-adrenoblocker bisoprolol does not lead to lowering of BP level and worsening of renal function, but is accompanied with development of hyperkaliemia in patients with CHF. Gynecomastia appears to be main reason limiting long term use of spironolactone in patients with CHF in a dose of 75 mg/day.