Rational Pharmacotherapy in Cardiology

Journal Information
ISSN / EISSN : 1819-6446 / 2225-3653
Published by: Stolichnaya Izdatelskaya Kompaniyaizdat (10.20996)
Total articles ≅ 1,568
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I. A. Zolotovskaya, V. D. Sabanova, I. L. Davydkin
Rational Pharmacotherapy in Cardiology, Volume 17, pp 294-302; doi:10.20996/1819-6446-2021-04-17

Anticoagulant therapy of patients with atrial fibrillation is an integral part of their treatment strategy. The high risk of developing a cardioembolic stroke and the high comorbidity of this group of patients necessitates a comprehensive approach to treatment, taking into account all available risk factors. Atrial fibrillation is often asymptomatic and timely detection of these patients can be one of the most important tasks in the complex of measures aimed at protecting patients from stroke. The European Society of Cardiology's 2020 guidelines suggest the use of a CC to ABC patient management strategy. This strategy involves a number of measures aimed at managing atrial fibrillation, including confirming the diagnosis, determining the characteristics of atrial fibrillation and treatment tactics. One of the points of this strategy is the control of comorbidities and risk factors for cardiovascular diseases. To date, rivaroxaban has a number of convincing and reliable data on a high profile of efficacy and safety in the treatment of comorbid patients who not only have a high risk of stroke, but also need protection from coronary events and decreased renal filtration function. These data are confirmed by both the results of randomized clinical trials and data from real clinical practice. The review discusses the literature data describing the condition of patients with atrial fibrillation while taking direct oral anticoagulants, according to the search query “Atrial fibrillation, effectiveness and safety of rivaroxaban, warfarin, comorbidity, atrial fibrillation, efficacy and safety of rivaroxaban, warfarin, comorbid status” for the period from 2010 to 2020 in open sources PubMed and e-library, and a strategy for the comprehensive protection of patients with atrial fibrillation when using rivaroxaban is proposed for consideration.
, T. L. Nguyen, G. N. Golukhov
Rational Pharmacotherapy in Cardiology, Volume 17, pp 341-350; doi:10.20996/1819-6446-2021-04-05

Chronic heart failure (CHF) occurs in 4.3-28% of patients with diabetes mellitus and is most often associated with the presence of coronary heart disease, arterial hypertension and the direct adverse effects of insulin-resistance, hyperinsulinemia and hyperglycemia on the myocardium. Diabetes mellitus occurs in 12-47% of patients with CHF and can develop within several years after a diagnosis of HF in 22% of patients due to insulin-resistance of failure tissues. The presence of diabetes mellitus leads to a greater severity of clinical symptoms and hospitalization rate, worsening of quality of life and prognosis in CHF. A decreased left ventricular ejection fraction is an independent predictor of the poor prognosis in the patients with diabetes mellitus. The algorithm of the treatment of CHF in the patients with and without diabetes mellitus is not fundamentally different, but it requires taking into account the metabolic effects of the prescribed drugs. Angiotensin receptor-neprilysin inhibitor are increasingly used in clinical practice and are gradually replacing angiotensin-converting enzyme inhibitors and sartans in CHF both without diabetes mellitus and in its presence. Recently, the effectiveness of type 2 sodium glucose cotransporter inhibitors has been proven in patients with CHF with and without diabetes mellitus. This review is devoted to the relationship of diabetes mellitus and CHF, as well as the approaches to the management of such comorbid patients.
, I. V. Goncharova, A. A. Vedernikov, , D. A. Napalkov
Rational Pharmacotherapy in Cardiology, Volume 17, pp 332-340; doi:10.20996/1819-6446-2021-04-14

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice that affects intracardiac hemodynamics and is accompanied by increased mortality due to the risk of stroke and systemic thromboembolism. In recent years, numerous studies, evaluating the use of biomarkers in AF patients, have been conducted to expand the possibility of stratification the complications risks. The aim of the review is to evaluate the possible isolated and combined predictive significance of NT-proBNP, troponin T (TnT) and D-dimer levels in the development and progression of AF and its thromboembolic complications according to published data. Determining the level of NT-proBNP can be used to diagnose cardioembolic stroke in latent forms of AF. Patients with a cardioembolic stroke have been shown to have higher BNP/NT-proBNP levels than patients with an atherothrombotic stroke and venous thromboembolism. Elevated TnT level is independently associated with AF detection as a cause of stroke. The assessment on the CHADS2 scale significantly correlates with the level of troponin I (TnI). However, it is equally important to take into account TnI level even with a low score of CHADS2. Patients with the level of TnI ≥ 0.040 pg/L are considered to be prescribed anticoagulants in the same way as the patients with high CHADS2 score. Similar results were obtained analyzing high-sensitivity cardiac troponin T (hs-cTnT) data. The level of D-dimer 0.315 mg/L was determined to be the optimal limit level for predicting the adverse functional outcome of stroke owing to AF. Patients with a high level of D-dimer have shown a high risk of developing thromboembolic and cardiovascular complications despite their taking anticoagulant drugs. D-dimer levels positively correlate with the CHA2DS2 and CHA2DS2-VASC scales of stroke risk stratification. The analysis of the biomarkers combination has revealed the increase of hs-cTnT and BNP associated with stroke in AF patients (p<0.05). However, ABC scale, including hs-cTnT and NT- pro BNP, hasn't given more accurate result in stroke predicting than CHA2DS2-VASc scale. The integration of biomarkers in predicting the risk of AF occurrence, progression and appearance of thromboembolic complications is a promising direction. An isolated level of biomarkers (hs-cTnT, NT-proBNP, D-dimer) and their combination with clinical risk factors can improve the quality of cardioembolic strokes prognosis.
A. A. Kulikov, O. V. Sapelnikov, T. M. Uskach, D. I. Cherkashin, I. R. Grishin,
Rational Pharmacotherapy in Cardiology, Volume 17, pp 270-277; doi:10.20996/1819-6446-2021-04-16

Atrial fibrillation is the most common arrhythmia in clinical practice. It is associated with an increased risk of stroke, chronic heart failure, and sudden cardiac death. Our options of restoring and maintaining sinus rhythm have a very limited effect, both in the case of antiarrhythmic and catheter treatment. Catheter ablation has proven to be a more effective approach than antiarrhythmic therapy. The success rate of the procedure reaches 70%. However, radiofrequency ablation is associated with a risk of complications, with 4.5% of patients likely to develop major complications, including tamponade (1.31%), femoral pseudoaneurysm (0.71%), and death (0.15%). Given the generally recognized dominant role of the pulmonary veins in the induction of atrial fibrillation, their electrical isolation has become the recommended tactic of the catheter approach. In the case of patients with paroxysmal form of atrial fibrillation, the success rate of the procedure reaches 87%. Unfortunately, in the case of persistent forms of atrial fibrillation, the effectiveness of the primary procedure decreases to 28% and reaches 51% with repeated interventions. In addition to the anatomically oriented isolation of the pulmonary veins, a number of strategies have been proposed to reach the secondary zones of atrial fibrillation induction. The results of recent studies on the effectiveness of strategies for ablation of rotor regions and their role in the induction and maintenance of AF may lead to the further development of catheter ablation techniques and an individual radiofrequency ablation approach in a particular patient.
V. G. Grachev, S. S. Vedenskaya,
Rational Pharmacotherapy in Cardiology, Volume 17, pp 239-248; doi:10.20996/1819-6446-2021-03-02

The similarity of the pathogenesis of atherosclerosis and atherothrombotic complications, regardless of their location, makes the approaches to secondary prevention similar, which include lifestyle modification, pharmacotherapy of hemodynamic disorders, metabolic changes and hemostasis. Secondary prophylaxis in patients with multifocal arterial lesions using antihypertensive, antithrombotic and lipid-lowering therapy provides a more pronounced decrease in the incidence of cardiovascular complications than in lesions of single vascular lesions due to a higher initial risk. However, these treatments do not reduce the risk to the level that is achieved by treating patients with less atherosclerotic lesion. In this regard, it is of interest to use the currently available new methods and regimens of drug therapy in patients with multifocal arterial lesions, which make it possible to more intensively influence the mechanisms of atherosclerosis progression and more effectively prevent the development of its complications.
, A. I. Tarzimanova
Rational Pharmacotherapy in Cardiology, Volume 17, pp 310-314; doi:10.20996/1819-6446-2021-03-01

At the end of 2020, a new term “post-COVID-19 syndrome” appeared in the medical community. The prevalence of this syndrome reaches more than 30% among patients who have had COVID-19, and its duration can vary from 12 weeks to 6 months. One of the most severe consequences of COVID- 19 is the defeat of the cardiovascular system, which has a variety of mechanisms: dysregulation of the renin-angiotensin-aldosterone system; pathological systemic inflammatory response; direct action of the virus on the myocardium with the development of myocarditis; respiratory failure with hypoxia, leading to damage to cardiomyocytes; microvascular damage due to hypoperfusion, increased vascular permeability, angiospasm and the direct damaging effect of the virus on the endothelium of the coronary arteries; thrombotic complications due to the procoagulant and prothrombogenic effect of systemic inflammation. One of the most promising directions in the treatment and prevention of damage to the cardiovascular system in patients with hypertension who have undergone COVID-19 is the appointment of antihypertensive drugs that have the most pronounced organoprotective properties together with statins. The single pill combination of lisinopril, amlodipine and rosuvastatin is an effective drug that allows achieving not only adequate hypotensive and lipid-lowering effects, but also due to its pronounced organoprotective properties, to expect a reduction in cardiovascular risk and complications in patients who have suffered a new coronavirus infection caused by the SARS-CoV-2 virus.
, S. B. Fitilev, , I. I. Shkrebneva, N. N. Shindryaeva, D. A. Klyuev, L. N. Stepanyan, A. M. Lutsenko, A. T. Tsai, A. A. Danilova
Rational Pharmacotherapy in Cardiology, Volume 17, pp 178-185; doi:10.20996/1819-6446-2021-03-03

Aim. To study medication adherence in elderly patients with coronary artery disease (CAD) in primary care practice. Material and methods. The study conducted in out-patient clinic of Moscow city. 293 elderly (≥65 years) patients with established CAD included. The following patient data obtained via electronic medical record system: demography, medical history, modifiable risk factors and prescribed pharmacotherapy. Level of medication adherence measured by Morisky scale (MMAS-8) via telephone survey. Results. According to Morisky scale high adherence was identified in 146 (49.8%) elderly patients, moderate adherence – in 99 (33.8%) patients, low adherence – in 48 (16.4%) patients. Analysis of specific questions of the scale done in non-adherent patients revealed signs of unintentional non-adherence due to forgetfulness (45.9%) and signs of intentional non-adherence due to patients feeling worse (35.8%) or better (28.4%). By means of dichotomic interpretation of Morisky scale results the population under research was divided into two groups: 147 (50.2%) non-adherent patients and 146 (49.8%) – totally adherent patients. These groups were comparable in terms of sex (female 71.2 vs 68.0%; p>0.05) and age (median 73.5 vs 73.0 years; p>0.05) distribution, and medical history: myocardial infarction (39.0% vs 38.8%), atrial fibrillation (37.0 and 41.5%), chronic heart failure (90.4% vs 91.2%), diabetes (26.7% vs 24.5%). There were fewer smokers in adherent group (0.7% vs 6.5%; p0.05). Drugs that improve prognosis were also prescribed comparably: antiplatelets (66.4% vs 61.9%; p>0.05), anticoagulants (36.3% vs 44.9%; p>0.05), statins (82.2% vs 79.6%; p>0.05), renin-angiotensin system inhibitors (89.0 and 87.8%; p>0.05). Adherent patients had lower mean values of lipids: total cholesterol (4.7±1.2 vs 5.2±1.4 mmol/l; p<0.05) and low density cholesterol (2.4±0.9 vs 2.8±1.2 mmol/l; p<0.05). Non-adherent elderly patients made more visits to general practitioner (median 5 vs 3 visits; p0.05). Conclusion. Half of elderly patients with CAD are non-adherent to treatment in primary care setting. Medical history and structure of pharmacotherapy do not influence level of adherence in this population. Among adherent patients fewer individuals smoke and mean values of lipids are lower. Non-adherent elderly patients cause higher load on general practitioner, supplementary pharmaceutical provision program provided no better adherence in the population under research.
, , , L. V. Vasil'Eva, , N. V. Lobova, E. E. Bykova, M. M. Khachuroeva
Rational Pharmacotherapy in Cardiology, Volume 17, pp 256-262; doi:10.20996/1819-6446-2021-04-08

The coronavirus pandemic showed not only an increase in levels of excess morbidity and mortality in the acute phase, but also persisting symptoms 4 weeks after the onset of the disease. A review of international studies on the prevalence and diversity of the manifestations of postcoid syndrome is presented. The data on such a manifestation of post-COVID syndrome as postural orthostatic tachycardia syndrome (POTS) are accumulating. Pathogenetic mechanisms, modern diagnostic criteria and research data on the prevalence of this syndrome are presented in the article. The Canadian Cardiovascular Society has proposed medications as a treatment for POTS, including the sinus node If channel inhibitor ivabradine. Data from several studies showing the effectiveness of this drug for POTS, including after suffering COVID-19, are presented in the article. Clinical data on the prevalence of tachycardia among patients admitted to the Sechenov University hospital are presented. About 18% of patients with hypertension and 21% of patients with normal blood pressure had a high heart rate. A clinical example of the use of ivabradine in a patient after a coronavirus infection is presented. Drug interactions and individual tolerance of ivabradine in patients after coronavirus infection are being discussed. The authors put forward the hypothesis about the further prospect of using ivabradine in the treatment of clinical manifestations of postcoid syndrome on the basis of literature data and their own experience.
Rational Pharmacotherapy in Cardiology, Volume 17, pp 323-331; doi:10.20996/1819-6446-2021-04-06

The current understanding of the management of patients with diabetes mellitus (DM) based on the concept of the cardiovascular continuum involves not only the prevention and treatment of cardiovascular diseases (CVD), but also the prevention and treatment of chronic kidney disease (CKD). The fact is that patients with DM and CKD represent a special group of patients with a very high risk of CVD and cardiovascular mortality. Such patients require early diagnosis and timely identification of risk factors for the development and progression of CKD for their adequate correction. Arterial hypertension, along with hyperglycemia, is the main risk factor for the development and progression of CKD in patients with diabetes. In this regard, the choice of antihypertensive therapy (AHT) in patients with diabetes is of particular importance. The basis of AHT in diabetes and CKD is the combination of a blocker of the renin-angiotensin-aldosterone system (an angiotensin-converting enzyme inhibitor [ACE inhibitor] or an angiotensin II receptor blocker [ARB]) and a calcium channel blocker (CCB) or a thiazide / thiazide-like diuretic. The task of the performed AHT is to achieve the target level of blood pressure (BP). At the same time, the optimal blood pressure values in patients with diabetes and CKD are blood pressure values in the range of 130-139/70-79 mm Hg. If the target blood pressure is not achieved, it is necessary to intensify antihypertensive therapy by adding a third antihypertensive drug to the therapy: CCB or a diuretic (thiazide / thiazide-like or loop). In case of resistant hypertension, it is necessary to consider the possibility of adding antagonists of mineralocorticoid receptors, other diuretics or alpha-blockers to the conducted AHT. Beta-blockers can be added at any stage of therapy if the patient has exertional angina, a history of myocardial infarction, atrial fibrillation, and chronic heart failure. The need to normalize blood pressure parameters by prescribing combined antihypertensive therapy in patients with diabetes and CKD is explained by a decrease in renal and cardiovascular risks, and, therefore, a decrease in the risk of mortality in this cohort of patients.
A. V. Pevzner, E. A. Kuchinskaya, V. G. Kiktev, G. I. Kheimets
Rational Pharmacotherapy in Cardiology, Volume 17, pp 315-322; doi:10.20996/1819-6446-2021-04-09

Vasovagal syncope (VVS) can occur in every third of human population. Clinical symptoms of VVS areas a result of arterial hypotension with critical global cerebral hypoperfusion due to vasodilatation and bradicardia. Bradicardia is manifested as sinus node dysfunction and atrioventricular conduction disturbances due to activation of nervus vagus. Asystole can take place in some cases. Lack of efficacy of permanent pacemaker founds in patients to prevent of VVS. The results of double blind placebo controlled studies, European and American expert's opinions, probable causes of lack of efficacy of pacemakers in such category of patients and way of solution of this problem are discussed in the review. Syncope recurrences in spite of pacemaker implantation, risk of surgery complications and good life prognosis are arguments for therapeutic approach, now suitable for the most of patients with VVS. Case report (VVS with asystole but without of pacemaker implantation) with successful follow-up is analyzed in the article.
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