Vol 22, No 1 (2020)

Interview with Dmitriy A. Napalkov, D. Sci. (Med.), Prof., Sechenov First Moscow State Medical University (Sechenov University).

Rheumatoid arthritis is a frequent and one of the most severe immuno-inflammatory diseases in humans, which determines the great medical and socio-economic importance of this pathology. One of the priority problems of modern cardiac rheumatology is an increased risk of cardiovascular complications in rheumatoid arthritis. This review discusses traditional cardiovascular risk factors for cardiovascular diseases (metabolic syndrome, obesity, dyslipidemia, hypertension, insulin resistance, diabetes mellitus, smoking and hypodynamia) and a genetic predisposition in patients with rheumatoid arthritis, as well as their specific features: "lipid paradox" and "paradox of obesity." It was noted that traditional risk factors for cardiovascular diseases are to some extent related and burdened by a systemic inflammatory process in rheumatoid arthritis, however, this relationship requires a more detailed review. The interaction of rheumatologists, cardiologists and first contact doctors (therapist and general practitioner) in studying the mechanisms of the development of atherosclerosis in patients with rheumatoid arthritis will allow in real clinical practice to develop adequate methods for the timely diagnosis and prevention of cardiovascular diseases in patients with rheumatoid arthritis.

Arterial hypertension (AH) chronotherapy includes using antihypertensive medications (AHM) in evenings that is especially rational in patients with disturbed daily rhythm of blood pressure (BP) changes (non-dipping, reverse dipping). Chronotherapy use results in increase of hypotensive therapy effect and normalization of nocturnal BP dipping as well as cardiovascular risk reduction. In large prospective studies (МАРЕС, n=3344, Hygia Chronotherapy Trial, n=19 084) intake of >1 medication in the evening resulted in significant additional decrease of all cardiovascular events by 61% and 45%, respectively. In chronotherapy evaluation for different AHM groups the best effect was seen in renin-angiotensin-aldosterone system antagonists (angiotensine transforming enzyme inhibitors, angiotensin II receptor blockers) and calcium antagonists. Chronotherapy advantages were shown in elderly patients, patients with resistant AH, and comorbid chronic renal disease and diabetes mellitus. According to randomized clinical studies results and metaanalyses in patients with AH and chronic renal disease intake of AHM in the evening resulted in normalization of 24-hour BP profile and achievement of renoprotective effect (proteinuria decrease, glomerular filtration rate increase), as well as in decrease of relative risk of cardiovascular outcomes almost by 70%. In МАРЕС study in patients with AH and diabetes mellitus evening intake of AHM also resulted in 24-hour BP profile normalization and significant decrease of risks by almost 70%. Apart from that, in patients without history of diabetes after chronotherapy use with evening intake of AHM apart from betel BP level control, three-fold decrease in diabetes mellitus incidence was observed (relative risk 0.43). Chronotherapy use in AH and comorbid disorders is an additional method of pharmacotherapy optimization that is safe for use in clinical practice.

Background. The working conditions of the railway staff are very hard; combine many cardiovascular disease risk factors, most often including arterial hypertension (AH). Aim. Research was to study heart rhythm disorders and total cardiovascular risk among members of locomotive crews with arterial hypertension. Materials and methods. The study included 106 railway employees (train drivers and assistant drivers) aged 47-63 years (53 employees with AH and 53 employees without AH). All patients passed through 12-channel daily ECG monitoring. There were evaluated heart rhythm disorders (ventricular and supraventricular), non-invasive predictors and markers of electrical myocardial instability (circadian profile, QT interval, ventricular late potentials, T-wave alternation, rhythm variability). To assess the total cardiovascular risk, the SCORE system was performed to calculate the risk of death due to cardiovascular incidents within the next 10 years, body mass index, blood glucose and total cholesterol, office blood pressure, as well as the presence of bad habits, such as smoking and alcohol intake. In addition to the traditional ones, we took into account professional (seniority) and psychosocial (level of situational and personal anxiety by the Spielberger-Hanin) factors of cardiovascular risk. Results. The study showed significant differences in cardiac rhythm disturbances between the two groups; ventricular rhythm disturbances in the form of ventricular tachycardia were registered only in group of railway employees with AH. There were identified markers of myocardial heterogeneity in patients with AH, namely, the indicators of ventricular TotQRSF and LAS40 predictors are higher, and RMS40 is significantly lower in this group. Blood pressure levels and body mass index were established as the most significant cardiovascular risk factors for this kind of occupation. It was also revealed a reliable relationship between seniority and the risk of death on the SCORE scale, as well as blood pressure, circadian profile and heart rate variability, the frequency of registration of paired polymorphic ventricular extrasystoles according to 12-channel daily ECG monitoring in locomotive team workers in both groups. Conclusion. The presence of arterial hypertension in locomotive crew employees is associated with a higher frequency of supraventricular rhythm disturbances and a higher risk of ventricular rhythm disturbances than in employees without arterial hypertension. Members of locomotive crews have moderate total cardiovascular risk, while individuals with arterial hypertension have higher body mass index values. In both examined groups, the seniority is directly related to both cardiovascular risk factors (blood pressure level, body mass index, risk of death within the next 10 years on the SCORE scale), as well as indicators of the circadian index and heart rate variability, ventricular rhythm disturbances according to daily ECG monitoring.

Background. Patients with multifocal atherosclerosis with maximal cardiovascular risk are at special place in the context of lipid-lowering therapy optimization. These patients require residual dyslipidemia correction to the fullest extent possible. Materials and methods. Effects of medication Vasosponine (ZAO “Vifitekh”, Russia) which is a source of vegetal saponins in a dosage 400 mg per day on serum lipid profile parameters were evaluated in patients with multifocal atherosclerosis and non-target levels of atherogenic lipoproteins while receiving optimal statin treatment. The study included 100 patients with stable coronary artery disease and high cardiovascular risk with an experience of myocardial infarction or percutaneous coronary intervention in the last 2-12 months and diagnosed with obliterating atherosclerosis of peripheral arteries - brachiocephalic arteries and/or lower extremities arteries. Study group (n=50) included patients who received combined lipid-lowering therapy: atorvastatin in dosage 40 mg per day + Vasosponine 400 mg per day along with baseline treatment. Control group included 50 patients receiving only atorvastatin in dosage 40 mg per day along with baseline treatment. Total duration of the study was 6 months: with screening for 30 days and patient follow-up for 90 days. The study included 3 endpoints at 1 st, 10th, and 90th days of treatment. Results. It was shown that adding of Vasosponine to treatment allows results in significant and stable decrease of total cholesterol level by 30.7% (p<0.001), low-density lipoprotein level by 37.2% (p<0.001), triglycerides level by 37.0% (p<0.0001), and atherogenic index by 39.5% after 90 days of treatment. Vasosponine was established to have good safety profile. Conclusion. Medications containing vegetal saponins may be used in escalation schemes of lipid-lowering therapy in patients who did not achieve target levels of lipids after treatment with optimal statin doses.

In the paper the authors report the first in Russia clinical case of successful transcatheter aortic valve implantation in high-risk patient with critical aortic stenosis and verified heparin-induced thrombocytopenia type 2 with use of direct thrombin inhibitor bivalirudin. The key issues of pathogenetic and diagnostical issues of verified heparin-induced thrombocytopenia, and up-to-date clinical evidence of bivalirudin as alternative medication for the controlled procedural anticoagulation in the setting of contraindication for heparin use are highlighted in the literature review.