Aim      This study presents the experience of managing patients with COVID-19 after cardiac transplantation (CT).

Material and methods  Infectious complications (IC) following CT are a leading cause for morbidity and mortality. A prolonged incubation period, atypical IC symptoms, and originally altered results of laboratory and instrumental diagnosis are characteristic of recipients due to immunosuppression. In 2020, the coronavirus infection (COVID-19) rapidly spread worldwide, and timely diagnosis and searching for effective treatments for this disease became a major challenge. From January 2010 through July 2020, 148 patients received orthotopic heart transplants at the V.A. Almazov National Medical Research Center; 34 of these patients died by the present time and were excluded from this analysis. 114 patients were included into the retrospective evaluation of results. These patients had been a part of the group followed up at the Center for more than a month.

Results From March through July 2020, 12 (10.5 %) of 114 CT recipients were infected with the virus SARS-CoV-2. In 75 % (n=9) of the sick patients, the COVID-19 infection developed after more than one year after CT. From the first day of clinical symptoms, mycophenolic acid/everolimus were temporarily suspended. The outpatient treatment was started on the first day and included an antiviral therapy (oseltamivir), mucolytics (bromhexine), vitamin C, and anticoagulants. If the disease onset was associated with pyretic fever the empiric antibacterial levofloxacin treatment was administered due to a high risk of mixed infection. Hospitalized patients with moderately severe COVID-19 (n=3) were treated with oxygen inhalation through nasal cannula and prone position with a positive effect.

Conclusion      Remote counseling of patients after CT and consistency of the outpatient treatment with recommendations of managing transplant physicians provided timely diagnosis of IC, early administration of treatment, and the absence of COVID-19 complications. Reducing the regimen of immunosuppressive therapy (antiproliferative agents) for up to 14 days facilitated infection control and was not associated with acute rejection crisis and/or impairment of the transplant function.

 

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.

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.

Aim      To evaluate structural characteristics of atherosclerotic plaques (ASP) by coronary computed tomography arteriography (CCTA) and intravascular ultrasound (IVUS).

Material and methods  This study included 37 patients with acute coronary syndrome (ACS). 64-detector-row CCTA, coronarography, and grayscale IVUS were performed prior to coronary stenting. The ASP length and burden, remodeling index (RI), and known CT signs of unstable ASP (presence of dot calcification, positive remodeling of the artery in the ASP area, irregular plaque contour, presence of a peripheral high-density ring and a low-density patch in the ASP). The ASP type and signs of rupture or thrombosis were determined by IVUS.

Results The IVUS study revealed 45 unstable ASP (UASP), including 25 UASP with rupture and 20 thin-cap fibroatheromas (TCFA), and 13 stable ASP (SASP). No significant differences were found between distribution of TCFA and ASP with rupture among symptom-associated plaques (SAP, n=28) and non-symptom-associated plaques (NSAP, n=30). They were found in 82.1 and 73.3 % of cases, respectively (p>0.05), which indicated generalization of the ASP destabilization process in the coronary circulation. However, the incidence of mural thrombus was higher for SAP (53.5 and 16.6 % of ASP, respectively; p<0.001). There was no difference between UASP and SASP in the incidence of qualitative ASP characteristics or in values of quantitative ASP characteristics, including known signs of instability, except for the irregular contour, which was observed in 92.9 % of UASP and 46.1 % of SASP (p=0.0007), and patches with X-ray density ≤46 HU, which were detected in 83.3 % of UASP and 46.1 % of SASP (р=0.01). The presence of these CT criteria 11- and 7-fold increased the likelihood of unstable ASP (odd ratio (OR), 11.1 at 95 % confidence interval (CI), from 2.24 to 55.33 and OR, 7.0 at 95 % CI, from 5.63 to 8.37 for the former and the latter criterion, respectively).

Conclusion      According to IVUS data, two X-ray signs are most characteristic for UASP, the irregular contour and a patch with X-ray density ≤46 HU. The presence of these signs 11- and 7-fold, respectively, increases the likelihood of unstable ASP.

 

Aim      To evaluate the dynamics of indexes of oxidative stress and markers of myocardial injury and dysfunction in patients with aggressive type lymphomas during the antitumor therapy.

Material and methods  This study included 75 patients with lymphoproliferative diseases of aggressive type. The main group consisted of 53 patients who received one course of antitumor therapy during the study. The comparison group consisted of 22 patients who have not received any specific treatment so far. Troponin I (TnI), high-sensitivity troponin (hsTnI), heart-type fatty acid binding protein (Н-FAВР), N-terminal pro-brain natriuretic peptide (NT-prоBNP), superoxide dismutase (SOD), and myeloperoxidase (MPO) were measured in patients of both groups at baseline, and in the main group, they were measured at 4 hours after administration of antitumor agents and on completion of the course. Functional status of the cardiovascular system was evaluated by electrocardiography in all patients at baseline and after the course of antitumor treatment and by echocardiography.

Results The chemotherapy was associated with increased levels of NT-prоBNP, SOD, and MPO (30.670±15.367 vs. 52.309±25.718 pmo l/l; 1.61±0.135 vs. 1.74±0.193 U/ml; and 507.54±91.51 vs. 742.3±49.01 ng/ml, respectively). The study results indicated activation of oxidative stress on the background of the administered antitumor therapy, progressive myocardial dysfunction, and increased frequency of arrhythmic episodes.

Conclusion      The study results allowed identifying NT-prоBNP, MPO, and SOD as important indexes for determining a patient group at high risk of cardiotoxicity during the antitumor treatment.

 

Aim      To study gender-related characteristics of vascular wall stiffness (VWS), central blood pressure (CBP), and BP diurnal profile in patients with arterial hypertension (AH) and depression.

Material and methods  This prospective, noninterventional study enrolled 161 patients, including 98 patients with AH and depression (50 (51 %) men and 48 (49 %) women) and 63 patients with AH without depression (32 (50.8 %) men and 31 (49.2 %) women. The 24-h BP monitoring (24-h BPM) with a BPLab Vasotens hardware system was performed for all patients. The following indexes were evaluated: mean diurnal, mean daytime, and mean nighttime systolic and diastolic BP (SBP and DBP); daytime and nighttime SBP and DBP time index; SBP and DBP variability; and suite of metrics characterizing VWS and CBP. Depression was diagnosed with the Hospital Anxiety and Depression Scale (HADS) and the Zung Self-Rating Depression Scale. Statistical analyses were performed using the STATISTICA 12 software.

Results In the patient group with AH and depression, practically all indexes of 24-h BPM were higher for men than for women (р<0.05). Most 24-h BPM parameters did not differ in groups of men and women without depression. Independent of gender, 24-h BPM parameters were significantly higher in patients with both AH and depression than in AH patients without depression. Adverse changes in major indexes of VWS and CBP, were more pronounced in men than in women with AH and depression (р<0.05). Adverse changes in most VWS and CBP indexes were more statistically significant for men with AH and depression than for men without depression.

Conclusion      The presence of depression in men and women with AH was associated with significant pathological changes in both BP diurnal profile and CBP and VWS parameters. Furthermore, adverse changes in indexes were more pronounced for men with depression than for women. The study results should be taken into account in administration of antihypertensive and psychocorrective drug therapy to personalize the treatment and provide not only optimization of diurnal BP profile but also vasoprotection.

Aim      To determine the type and incidence of ictal bradyarrhythmias in patients with drug-resistant types of epilepsy by long-term electrocardiogram (ECG) monitoring.

Material and methods  Subcutaneous ECG monitors programed for recording pauses >3 sec and episodes of bradycardia ≤45 bpm were implanted in 193 patients with persistent epileptic seizures without organic pathology of the myocardium. Recording was activated by the patient/family at the onset of epileptic seizure. The follow-up period was 36 months with visits to the clinic every three months.

Results For 36 months of monitoring, 6494 ECG fragments were recorded. Ictal bradycardia was observed in 6.7 % of patients, including ictal asystole in 2.6 % of patients. Episodes of bradycardia and asystole during epileptic seizures were transient and developed significantly more frequently in men, patients with long duration of the disease, bilateral tonic-clonic or focal seizures with disorder of consciousness, during sleep, on the background of treatment with several antiepileptic agents, mostly from the group of potassium channel blockers.

Conclusion      Bradyarrhythmias accompanying epileptic seizures are transient and reproducible from seizure to seizure. They reflect functional changes in the myocardium and do not determine the life prediction for patients with epilepsy without organic pathology of the heart.

This article presents current opinions on the role of antithrombotic therapy in secondary prevention of cardiovascular diseases (CVD) in patients after noncardioembolic stroke or a transient ischemic attack on the background of sinus rhythm. This review analytically analyses evidence-based data on antithrombotic drugs used for this secondary prevention. Despite the fact that acetylsalicylic acid (ASA) is still a “gold standard” for prevention of noncardioembolic stroke, the search for rational combinations of antithrombotic drugs to increase the effectiveness of preventive treatment is relevant. The question whether the rivaroxaban treatment as monotherapy or in combination with ASA is more effective than the ASA monotherapy for secondary prevention of cardiovascular complications (CVC) was addressed in the COMPASS study. In that study, three regimens of antithrombotic therapy were compared in patients with stable atherosclerotic CVD: rivaroxaban (2.5 mg twice a day) in combination with ASA (100 mg/day); rivaroxaban (5 mg twice a day); and ASA (100 mg/day). Risk for development of major CVC (death, stroke, myocardial infarction (IM)) was lower (p<0.001) in the rivaroxaban+ASA combination treatment group than in the ASA monotherapy group; however, the risk of major bleedings was somewhat higher. Total risk based on the definition of “pure clinical benefit” was lower for the rivaroxaban+ASA combination treatment than for the ASA monotherapy. The rivaroxaban monotherapy did not result in a significant decrease in the risk of major CVC compared to the ASA monotherapy but significantly increased the risk of major bleedings. Incidence of repeated ischemic stroke for a year was 1.1% for the combination therapy, 2.6% for the rivaroxaban therapy, and 3.4% for the ASA monotherapy with significant differences between the combination treatment group and the ASA monotherapy group (p<0.01). Relative risk of repeated stroke was 67% lower for the combination therapy group compared to the ASA monotherapy group. The combination of rivaroxaban (2.5 mg twice a day) and ASA (100 mg) opens a new epoch of antithrombotic treatment for primary and secondary prevention of stroke in patients with a stable atherosclerotic CVD and sinus rhythm.

Asymptomatic hyperuricemia (HU) is widespread in the population. Results of multiple studies have demonstrated independent associations between increased levels of uric acid and risk of arterial hypertension, cardiovascular diseases, and chronic kidney disease. HU is considered as an independent predictor of cardiovascular and all-cause mortality. Despite the extensive study of this issue, there is still no unified answer to questions regarding the necessity of urate-lowering therapy in asymptomatic HU, whereas results of studies on the effect of this therapy on outcomes of cardiovascular and kidney diseases are controversial. This review summarized the basic, currently available information on this issue.

Echocardiography allows evaluating left ventricular (LV) myocardial contractility; however, the visual assessment of contractility is subjective and requires considerable experience. Modern technologies for assessment of LV myocardial contractility, such as tissue Doppler and speckle-tracking echocardiography, provide quantitative estimation of various parameters of myocardial strain, including the LV postsystolic shortening. Several studies have demonstrated the value of postsystolic shortening for evaluation of myocardial ischemia and “ischemic memory” in patients with cardiovascular diseases. This review analyzes experimental and clinical studies that addressed LV postsystolic shortening.

 

This review addresses current views on prevention of infectious endocarditis (IE). History of establishing the concept of antibacterial prophylaxis (ABP), major approaches, and substantiation of changes in ABP in recent years are described. Recent international and national guidelines are highlighted, specifically, guidelines of the European Society of Cardiologists, American Heart Association/American College of Cardiology, and the Japanese Circulation Society. The review presents critical evaluation of previously approved international guidelines, including analysis of the effect of partial or complete ABP restriction on IE morbidity and incidence of complications. Special attention is paid to awareness of practitioners, particularly dentists, about ABP issues in their practice. Aspects of validity and key features of preventive approaches in implanting cardiac electronic devices and transcatheter aortic valve implantation are discussed.

In this manual, the authors focused on the principal methods for diagnosis of peripheral artery disease in cardiological patients, from the interview and physical examination to functional tests and vascular visualization. Diagnostic and prognostic value of each method, its potentialities for reducing the risk of cardiovascular events (CVE), including myocardial infarction (MI), ischemic stroke (IS) or extremity amputation in critical ischemia, and overall mortality are discussed. The authors provided current information about a possibility of reducing the risk of CVE by intensifying the antithrombotic therapy according to results of the COMPASS study.