Vol 23, No 6 (2021)


Immune thrombocytopenia and thrombosis. Hematological paradox or clinical reality?

Dvoretsky L.I.


One of the features of primary immune thrombocytopenia is the development of thrombosis in patients, the incidence of which exceeds that in the population. The review provides epidemiological data on thromboembolic events, pathogenetic mechanisms and risk factors for their development, therapeutic tactics in this category of patients. In patients with immune thrombocytopenia, the following factors are important for the development of thromboembolic events: the pathogenetic features of the disease itself (increased functional activity of young platelets, platelet microparticles, antiphospholipid antibodies, activation of complement, an increase in the level of procoagulants, a decrease in the activity of ADAMTS13), the presence of comorbid risk factors for thrombosis, thrombogenic adverse effects of drugs used to treat immune thrombocytopenia. Therapeutic tactics of managing patients with immune thrombocytopenia who develop thromboembolic events consists in correcting the number of platelets (glucocorticoids, intravenous immunoglobulin) and administration of antithrombotic agents, given the clinical situation and the number of platelets.
Consilium Medicum. 2021;23(6):463-468
pages 463-468 views

Injury of vascular endothelium and erythrocytes in COVID-19 patients

Buryachkovskaya L.I., Melkumyants A.M., Lomakin N.V., Antonova O.A., Ermiskin V.V.


Aim. Caused by SARS-CoV2 virus coronavirus disease (COVID-19) is characterized not only by the lung deterioration but be serious injury of vascular endothelium and system of hemostasis. We investigated changes in blood cellular elements in patients at admission and discharge from the hospital. Materials and methods. Samples of venous blood of 31 patients of the hospital with a confirmed diagnosis of COVID-19 (28 with average and 3 with severe degree) were analyzed using electron microscopy and citofloumetry. The blood was taken from cubital vein at admission and on discharge the patients. Results. Electron microscopy showed that at admission to the hospital the number of circulating endothelial cells in all patients was significantly (40-100 times) greater compared to healthy persons. Numerous fenestrae are revealed in EC membrane. Their diameter comparable to the size of supercapsid in SARS-CoV-2 virus which attests the penetration of the virus into EC where it replicated and returned to circulation. As a result, the blood vessels denuded, their permeability increased resulting in tissue edema, inflammation, activation of the platelets, and pronouncedly augmented thrombosis. Infection with COVID-19 provoked formation of stacked (aggregated) red blood cells capable to clog microvascular bed and to diminish oxygen supply to the tissues. In some patients, such abnormalities persisted even on discharge from the hospital Conclusion. Analysis of the blood on discharge from the hospital showed that despite normalization of basic hematological parameters characteristic of inflammation, the virus-induced negative effects were not entirely eliminated. These sequelae can provoke the post-COVID syndrome in patients who endured COVID-19.
Consilium Medicum. 2021;23(6):469-476
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10 years of ARISTOTLE trial: results and lessons

Ostroumova O.D., Butorov V.N., Mironova E.V., Doldo N.M.


In 2021, the world cardiology community celebrates the anniversary of one of the greatest research in clinical medicine - the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study. The study showed that in patients with atrial fibrillation, the use of apixaban was more effective than the use of warfarin in the prevention of stroke or systemic embolism, was accompanied by a lower frequency of bleeding and was associated with lower mortality from all causes. To date, 77 subanalyses of this ambitious study have been published, a brief overview of which is given in the article. As shown by the post-hoc analysis of the ARISTOTLE study, apixaban was equally effective and safe both in patients without comorbidities and in polymorbid patients. The efficacy and safety of apixaban has been demonstrated in atrial fibrillation and in the presence of comorbidities, including diabetes mellitus, chronic kidney disease, obesity, and coronary heart disease. A number of subanalyses of the ARISTOTLE study are devoted to the prognostic assessment of biomarkers such as cardiac troponins, growth differentiation factor-15, pro-B-type N-terminal natriuretic peptide, D-dimer, asymmetric and symmetric dimethylarginine, interleukin-6, C-reactive protein. Based on the study of biomarkers, new, more informative scales for assessing the risk of stroke, death and bleeding were created: the ABC-stroke scale, the ABC-lethal outcome scale and the ABC-bleeding scale. The data of the corresponding sub-analyzes confirmed the greater efficacy and/or safety of apixaban treatment compared with warfarin, regardless of the level of various biomarkers in blood plasma and the degree of risk of stroke, death and bleeding, assessed using both traditional and new scales.
Consilium Medicum. 2021;23(6):477-484
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Modern strategy in the treatment of arterial hypertension: combination therapy and fixed combinations

Leonova M.V.


The introduction of fixed combinations for the treatment of arterial hypertension (AH) is an effective strategy to address the public health burden of cardiovascular disease. This strategy is reflected in modern international guidelines for the treatment of AH and is supported by World Health Organization. The use of fixed combinations allows solving key practical problems to achieve better results and improve the prognosis of AH: ensuring the greatest decrease in blood pressure (BP) and a lower target BP level, shortening the time period for obtaining target BP, increasing adherence to treatment. Fixed combinations include classes of antihypertensive drugs, which, when combined, have an additive or synergistic effect in lowering BP, help to reduce/mitigate side effects, reduce the number of pills and increase patient adherence, solving the problem of polypharmacy. Single dosing per day of fixed combinations is another important benefit, providing adherence, longer duration of action, and reduced diurnal fluctuations in BP. The clinical benefits of fixed combinations have been confirmed in a number of large studies and meta-analyzes. The modern tactics of using fixed combinations provides for their use at different stages/degrees of BP increase. In this regard, fixed combinations with subtherapeutic, therapeutic and maximum therapeutic doses of components have been developed. For the use of fixed combinations as an initial therapy for AH, drugs with subtherapeutic doses of components that are not used in monotherapy are proposed. In such cases, thanks to the complementary selection of combined drugs, it is possible to achieve a more significant and timely BP reduction, with fewer side effects. Modern fixed combinations are based on three main classes of antihypertensive drugs - RAAS blockers (ACE inhibitors and ARBs), calcium antagonists and diuretics. There are 2 principal approaches to combinations: a combination of RAAS blockers with diuretics (diurethic-use) or a combination of RAAS blockers with calcium antagonists (diuretic-free). This preference is due to evidence-based medicine data, including questions of efficacy, tolerability, side effects, and confirmation in clinical trials. In the clinical guidelines for the treatment of hypertension, these combinations are considered preferred (evidence level A). Over time, more and more fixed combinations become generic and reliable generic combination drugs for the treatment of hypertension appear, which reduces the cost factor and makes the therapy economically acceptable.
Consilium Medicum. 2021;23(6):485-490
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The relevance of prescribing triple neurohormonal blockade in real clinical practice: the role of mineralocorticoid receptor antagonists

Zhirov I.V.


In the article is outlined the main concepts use of the mineralocorticoids receptors antagonists in the treatment of congestive heart failure and systolic dysfunction after acute myocardial infarction. Claimed the pivotal role of eplerenone in the long-term treatment strategy due to decrease of mortality and improving the clinical outcomes.
Consilium Medicum. 2021;23(6):491-497
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Complex therapy of a multimorbid patient: focus on the reproducible drugs

Larina V.N.


Chronic noncommunicable diseases are associated with high mortality and high costs of medical care, and therefore require safe, effective and affordable therapy. When choosing a generic drug, a doctor may be guided by the assumption that the bioequivalence of medicinal substances is an indirect confirmation of their therapeutic efficacy. Absolute confidence in the same efficacy of original and generic drugs can only emerge after well-designed studies comparing therapeutic equivalence. The results of the Russian multicenter, open, randomized KARDIOKANON study, the purpose of which was to compare two options for complex therapy based on the use of only original or only generic drugs in persons with stable coronary artery disease, showed the comparability of the effectiveness of original and reproducible drugs of the pharmaceutical company "Canonpharma Production” in achieving the target value of arterial pressure, heart rate, low density lipoprotein and impact on quality of life. A sufficient variety of drugs produced by this pharmaceutical company opens up opportunities for the appointment of any of them, but further large controlled studies are needed to finally confirm the bioequivalence, therapeutic efficacy and interchangeability of original and reproducible drugs.
Consilium Medicum. 2021;23(6):498-503
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Tactics of management of patients with cardiovascular diseases. Roundtable report

Konradi A.O., Baranova E.I., Gurevich V.S., Zvartau N.E., Konstantinov V.O., Nifontov E.M., Obrezan A.G., Panov A.V., Sitnikova M.Y.


On September 25, 2020, in St. Petersburg, a round table was held with the support of Abbott company "Tactics of management of patients with cardiovascular diseases", dedicated to a modern interdisciplinary approach to the management of patients with cardiovascular diseases (CVD) with the participation of leading Russian cardiologists. CVD are one of the leading causes of adult mortality in both developing and developed countries. The key issues in the management of patients with CVD include the high incidence of comorbidity, which, according to the cardiovascular continuum, has a mutual negative effect on the course and prognosis of diseases. CVD are most often associated with metabolic disorders such as metabolic syndrome and type 2 diabetes mellitus. Currently, there is a need to correct the existing approaches to the management of CVD patients with comorbid metabolic disorders in order to optimize and improve the effectiveness of measures by health professionals. The article is devoted to aspects of a modern interdisciplinary approach to the management of patients with CVD.
Consilium Medicum. 2021;23(6):504-510
pages 504-510 views

Dyslipidemia. Barriers on the way of the patient to the implementation of medical recommendations

Sumarokov A.B.


Non-adherence is a frequent pattern in patients with dyslipidemia. Reasons of this are not only medical problem. Non-adherence influences on longterm life prognosis in cardiovascular disease. Problems of non-adherence and barriers front to patient and his physician discussed.
Consilium Medicum. 2021;23(6):511-516
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Holter monitoring in patients with stable cad: new opportunities

Fedulaev Y.N., Makarova I.V., Pinchuk T.V., Andreeva O.N.


Background. Noninvasive diagnosis of coronary artery disease (CAD) represents a real problem in clinical practice and can be improved by use of novel additional Holter ECG options. Aim. To evaluate the markers of electrical inhomogeneity of repolarization process in patients with various degree of coronary atherosclerosis. Materials and methods. All 116 patients, hospitalized for diagnostic coronary angiography, were divided into three groups: 1 - severe coronary atherosclerosis, 2 - initial atherosclerosis, 3 - normal coronary arteries (control group). A 12-lead Holter electrocardiography was performed to evaluate microvolt T-wave alternans (MTWA), QT and QTc dispersion on maximal and minimal heart rate (QTdmax and QTcdmax, QTdmin and QTcdmin respectively). Results. Results of a comparative analysis have demonstrated significant differences between three mentioned groups referring to MTWA (р=0,015). QTdmax (р1-2<0.001, р1-3=0.002) as well as QTcdmax (р1-2<0.0001, р1-3=0.001) were significantly higher in group 1 compared to others. At the same time, QTdmin and QTcdmin values didn't differ between the groups. The results of a current study indicated increased absolute values of the markers of an impaired repolarization in individuals with severe coronary atherosclerosis (compared to initial atherosclerosis and normal coronary arteries). Conclusion. The markers of electrical inhomogeneity of repolarization process in the myocardium (MTWA, QTdmax and QTcdmax) represent perspective ECG instruments in evaluation of the severity of coronary atherosclerosis in patients with stable CAD, still requesting futher investigation.
Consilium Medicum. 2021;23(6):518-521
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Dinical value of blood biomarker ST2 in patients with chronic heart failure

Alieva A.M., Pinchuk T.V., Almazova I.I., Ettinger O.A., Valiev R.K., Batov M.A., Nikitin I.G.


Stimulating growth factor expressed by gene 2 (ST2) and natriuretic peptides (BNP and NT-proBNP) reflect the flow of two different, but intersecting biological processes, so the markers provide independent and complementary information on the patient's condition. Being markers of hemodynamic instability or stretching of cardiomyocytes NT-proBNP/BNP is more suitable for detecting chronic heart failure, but this is not enough to rehospitalize patients for 30 days with the predictive qualities of this marker. ST2 is the strongest and clinically significant prognostic marker of cumulative cardiovascular events and mortality. The use of new highly specific cardiobiomarkers will make it possible to predict the development of cardiovascular complications with a high degree of predictive value, and therefore will allow prophylactically prescribing appropriate pathogenetic therapy aimed at improving the quality of life of patients, reducing mortality from cardiovascular diseases and reducing the economic costs of the state for treating heart failure and cardiovascular complications.
Consilium Medicum. 2021;23(6):522-526
pages 522-526 views

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