Aim. To evaluate the role of growth differentiation factor-15 (GDF-15) in long-term prognosis in patients with uncomplicated myocardial infarction (MI).

Material and methods. The study included 118 patients with uncomplicated ST-elevation and non-ST-elevation MI. In addition to the routine examination, all patients were analyzed for GDF-15, as well as the N-terminal pro-brain natriuretic peptide (NT-proBNP) by enzyme immunoassay in the first 48 hours from the onset of MI symptoms. The changes in the patients' condition were assessed by questioning after 1, 3, 6, 12 months, as well as the analysis of medical records in the event of repeated cardiovascular events and deaths. The endpoints were cardiovascular death, hospitalization for recurrent MI, and/or unstable angina. To assess the value of quantitative variables in predicting recurrent cardiovascular events, the ROC analysis was used. The survival function of patients was assessed using the Kaplan-Meier method.

Results. Twelve-month follow-up revealed 29 recurrent cardiovascular events, including 2 deaths and 8 recurrent MIs. GDF-15 was predictive of recurrent cardiovascular events with a sensitivity of 77,3% and a specificity of 56,2% (ROCAUC, 0,7±0,065 (95% confidence interval (CI), 0,572-0,827), p=0,004). Patients with GDF-15 ≥2,075 ng/mL had a higher risk of recurrent cardiovascular events (hazard ratio (HR), 3,4 (95% CI, 1,342-8,613), p=0,005). Another prognostic factor influencing the rate of recurrent cardiovascular events was NT-proBNP. An NTproBNP level ≥578 pg/mL was associated with an increased risk of cardiovascular death and rehospitalization for unstable angina and recurrent MI (HR, 4,3 (95% CI 1,828-10,239), p=0,00019).

Conclusion. The combined increase in GDF-15 ≥2,075 ng/mL and NT-proBNP ≥578 pg/mL in patients with uncomplicated MI increases the risk of recurrent cardiovascular events over the next 12 months (HR, 4,5 (95% CI, 2,087-9,736), p=0,00018).

Aim. To study laboratory and magnetic resonance imaging (MRI) characteristics of infarction area depending on left ventricular (LV) global systolic function in patients with acute myocardial infarction (AMI) after revascularization.

Material and methods. A total of 78 patients with primary AMI were included. On days 7-10, contrast-enhanced cardiac MRI was performed. Blood brain natriuretic peptide (BNP) was analyzed. Cardiac MRI was used to determine the characteristics of scar tissue, peri-infarct zone (PIZ), microvascular obstruction (MVO), intramyocardial hemorrhage (IMH) and the global contrast index.

Results. According to the MRI, patients were divided into following groups: group 1 — LV ejection fraction (LVEF) ≥50% (n=50), group 2 — LVEF 40-49% (n=21), group 3 — LVEF <40% (n=7).

The BNP in groups 1, 2, 3 was 106,8 (37,5; 248), 232,6 (170,1; 337,7) and 548,5±236,4 ng/ml, respectively (p_1-3<0,05). The scar tissue mass in groups 1, 2, 3 was 10,3 (2,4; 20,0), 34,7±21,3, 59,4±37,6 g, respectively (p_{1-2, 3}<0,01). PIZ differences were found only between patients with preserved and mildly reduced EF. MVO was diagnosed in 26% of patients with LVEF ≥50%, in 47,6% of patients with LVEF of 40-49% and 85,7% with LVEF <40% (p_1-3<0,01). The detection rate of IMH prevailed in the 2^nd group (33,3%) compared with the 1^st group (12%) (p_1-2<0,05). The global contrast index was the lowest in the 1^st group (14,7 (8,8; 27,9)%), intermediate in the 2^nd group (33,3±12,6%), the highest in the 3^th group (54,2±19,5%) (р_{1-2, 3; 2-3}<0,05).

Conclusion. The following risk factors for a decrease in LV systolic function in patients with AMI after revascularization were identified: the size of scar tissue, PIZ, MVO and IMH characteristics, global contrast index, BNP level.

Aim. To compare the incidence of leptin resistance (LR) in patients with acute and chronic coronary artery disease (CAD) and patients with acquired heart defects (AHD).

Material and methods. The study included 234 patients: 114 patients with acute myocardial infarction (MI) and 120 patients with chronic CAD. The comparison group consisted of 48 patients with degenerative non-rheumatic AHD — aortic stenosis (AS). The control group consisted of 40 healthy volunteers. On the 1st day of hospitalization, the concentration of leptin and leptin receptor was measured, and the free leptin index (FLI) was assessed. LR was recorded at leptin >6,45 ng/ ml and FLI >25. Statistical data processing was carried out using the software package Statistica 10.0 and SPSS 17.0 for Windows.

Results. Initially, LR in MI, chronic CAD and non-coronary disease was revealed in 64%, 56,2% and 25%, respectively. Significant differences in the incidence of LR were observed between patients with MI and chronic CAD relative to patients with AHD (p=0,02 and p=0,03, respectively), while no differences were found between patients with coronary pathology (p=0,82). Equation of patients for body mass index (BMI) did not affect the incidence of LR. High incidence of LR remained for patients with acute and chronic CAD, and amounted to 63% and 57,3%, respectively, while for patients with AS — 25%.

Conclusion. Patients with acute and chronic CAD are characterized by a high LR incidence, in contrast to patients with AHD. The number of LR cases in patients with coronary pathology did not depend on BMI values, which indicates possible alternative leptin sources contributing the development of hyperleptinemia. In addition, studying the mechanisms underlying the leptin receptor decrease in CAD is necessary for adequate leptin effects and the prevention of LR.

Aim. To determine the prognostic significance of cardiac regional mechanical dyssynchrony (MD), assessed by radionuclide equilibrium ventriculography (REVG) in candidates for cardiac resynchronization therapy (CRT).

Material and methods. The study included 65 patients with indications for CRT according to current guidelines. Prior to CRT, all patients underwent REVG to assess cardiac contractile function and MD. According to the phase analysis, indicators of global and regional cardiac MD were evaluated: phase standard deviation (PSD), histogram band width (HBW), entropy, and interventricular dyssynchrony. The regional assessment included an evaluation of phase histograms obtained from the analysis of the contraction of certain walls: left ventricular (LV) anterior, lateral, posterior wall, right ventricular (RV) free wall, and the interventricular septum. To evaluate the effectiveness of treatment 6 months after CRT, all patients underwent echocardiography, on the basis of which patients were divided into groups of responders and non-responders.

Results. REVG revealed significant differences in the initial regional MD values between the groups of responders and non-responders: in responders, MD values of RV free wall (PSD: 39 (28-67) vs 28 (20-50), p=0,03) and LV anterior wall (PSD: 28,5 (16-40) vs 14 (11-24), p=0,0005) were higher, and the LV lateral wall was lower (PSD: 10 (7-14) vs 15 (9-26), p=0,007) than in non-responders. Multivariate logistic regression found following independent predictors of a positive response to CRT: heart failure of ischemic origin, LV HBW, RV free wall PSD, anterior wall PSD, LV lateral wall HBW (p<0,001). The sensitivity and specificity of the model was 93% and 91%, respectively.

Conclusion. Regional MD scintigraphy parameters increase the predictive value of REVG in CRT candidates. The most informative in this regard are the PSD of RV free wall and LV anterior wall, as well as the HBW of LV lateral wall.

Aim. To study the prevalence of iron deficiency (ID) and anemia, as well as their impact on the clinical performance and quality of life in patients with acute decompensated heart failure (ADHF).

Material and methods. The work was performed as part of cross-sectional multicenter screening study of ID in patients with heart failure (HF), managed by the Russian Society of Heart Failure. We examined 80 patients hospitalized in the cardiology department due to ADHF, who signed an informed consent. The diagnosis of ADHF was based on clinical signs of decompensated heart failure requiring intravenous therapy with diuretics, vasodilators, or inotropic agents.

Results. The prevalence of ID was 80,0%, anemia — 35,0%, combination of anemia and ID — 31,2%. The mean age of patients with ID was 69,4±10,9 years. Patients with ID had higher HF class (40,6% vs 6,3% without ID, p<0,001), a higher incidence of hydrothorax (65,6% vs 31,3%, p=0,012), higher N-terminal pro-brain natriuretic peptide (5155,5 [3267,3;9786,3] pg/mL vs 2055,5 [708,8;2839,0] pg/mL, p<0,001), lower 6-minute walk test distance (155,9±84,0 m vs 239,6±82,7 m in patients without ID, p=0,01), lower quality of life according to the visual analogue scale (36,4±16,3 vs 46,3±20,7, p=0,036). ID was more often recorded in patients with frailty (95,7% vs 73,7% in patients without frailty, p=0,003), requiring a higher starting dose of intravenous diuretics (50,9±18,9 mg vs 38,6±12,3 mg without ID, p=0,021).

Conclusion. In patients hospitalized due to ADHF, the prevalence of ID is 80,0%, anemia — 35,0%, combination of ID and anemia — 31,2%. Patients with ID have a higher N-terminal pro-brain natriuretic peptide level, more severe signs of decompensation, which requires higher starting dose of loop diuretics. Patients with ID are more likely to have frailty, lower exercise tolerance and quality of life.

Aim. To evaluate the prognostic role of atrial fibrillation (AF) as a predictor of adverse events and outcomes in a cohort of patients with non-compaction cardiomyopathy (NCCM).

Material and methods. We examined 216 patients with NCCM (140 men and 76 women, median age, 39 (30; 50) years). In addition to traditional clinical methods, all patients underwent late gadolinium-enhanced cardiac magnetic resonance imaging (MRI). The endpoints of the study included progression of NYHA class III heart failure (HF) with the need for hospitalization, ventricular tachyarrhythmias, and thromboembolic events (TEEs).

Results. There were 54 out of 216 (23,6%) patients with AF, of which 18 had paroxysmal AF, 16 — persistent AF, and 20 — permanent AF. During the follow-up period (median follow-up, 36 (6; 72) months), 98 out of 216 (45,4%) patients with NCCM had adverse events and outcomes as follows: 16 (7,4%) had ventricular tachyarrhythmias, of which 12 (5,6%) — sudden cardiac death with successful resuscitation and implantation of an implantable cardioverter-defibrillator; 62 (28,7%) patients had NYHA III-IV class HF progression; 20 (9,3%) patients had TEEs. The rate of adverse cardiac events was significantly higher in patients with AF (74,1% vs 35,8%, χ²=23,93, p<0,001) compared with patients without AF, including the incidence of TEEs (20,4% vs 5,6%, χ²=10,58, p=0,002) and HF progression to class III (46,3% vs 22,8%, χ²=10,9, p=0,002).

Multivariate analysis showed that the following most significant predictors of HF progression risk: left ventricular ejection fraction (LVEF) <50% according to cardiac MRI (hazard ratio (HR), 95,8; 95% confidence interval (CI), 10,2 -898,6; p=0,0001), presence of AF (HR, 8,2; 95% CI, 2,2-31,3; p=0,0022) and left atrial volume index (LAVI) >43 ml/m² (HR, 5,2; 95% CI, 2,1-12,8; p=0,0004); predictors of TEE risk were the presence of AF (HR, 6,5; 95% CI, 2,0-20,8; p=0,0020) and LAVI >43 ml/m² (HR, 6,0; 95% CI, 1,8-19,7; p=0,036). No association of AF with ventricular tachyarrhythmias was found in the study cohort of patients with NCCM. Predictors of ventricular tachyarrhythmias were LVEF <50% (HR, 4,5; 95% CI, 2,950,4; p=0,0241) and the presence of non-sustained ventricular tachycardia (HR, 3,5; 95% CI, 1,3-9,3 p=0,0139).

Conclusion. The present study shows that, along with the traditional predictor of adverse events in patients with NCCM (LVEF <50%), the identified additional predictors (AF and LAVI >43 ml/m²) can be used to identify patients at high risk of complicated NCCM for the timely prevention and treatment.

Aim. To determine additional factors and sex differences associated with the intermediate probability of heart failure (HF) with preserved ejection fraction (HFpEF) in asymptomatic patients working in the Arctic on a rotating basis.

Material and methods. In the polar village of Yamburg (68° 21' 40 "N), 99 men and 81 women with grade 1 and 2 hypertension (HTN) and normal blood pressure, comparable by age (p=0,450), length of service in the north (p=0,956), office systolic blood pressure (BP) (p=0,251), diastolic BP (p=0,579) were simultaneously examined. We performed echocardiography and assessed the risk of HFpEF by H2FPEF score (Heavy; Hypertensive; Atrial Fibrillation; Pulmonary Hypertension; Elder; Filling Pressure). A treadmill test, Baevsky index, 24-hour BP monitoring, and biochemical blood tests were performed.

Results. Depending on H2FPEF score, participants were divided into groups: from 0 to 1 (group 1 — normal), from 2 to 5 (group 2 — intermediate probability of HFpEF). In men with intermediate probability of HFpEF, the Baevsky index (p=0,0048) and the incidence of resting body reserve dysaptation (p=0,0394) were higher, as well as a rapid BP increase during dosed exercise (p=0,0058) and a decrease in chronotropic reserve (p<0,0001) were noted. The presence of HTN in men increased the intermediate probability of HFpEF by 3,6 times, dyspnea at dosed exercise by 10 times, dysaptation to exercise by 5 times, the presence of left ventricular concentric remodeling by 8-10 times. In females with intermediate probability of HFpEF, dysaptation to exercise at rest (p=0,0120) and lower level of oxygen consumption during dosed exercise was more often determined (p=0,0485). The intermediate probability of HFpEF in women increased with autonomic nervous system dysfunction, an increase in the mean 24-hour systolic BP variability, the presence of dyspnea during dosed exercise (10 times), concentric left ventricular remodeling, and an increase in nonspecific inflammation markers (high-sensitivity C-reactive protein, IL-1β, IL-6).

Conclusion. Early identification of additional risk factors for intermediate probability of HFpEF in asymptomatic hypertensive patients has the potential to reduce the risk of subsequent clinical heart failure, allowing focus on prevention and intervention strategies in this group of patients.

Aim. To assess the survival rate of patients after cerebrovascular accident (CVA), depending on the visits to the local outpatient clinic and the type of medical supervision, and in the first year after hospital discharge.

Material and methods. The outpatient part of the REGION-M registry included 684 patients assigned to the City Polyclinic № 64 of Moscow, discharged from the F. I. Inozemtsev City Clinical Hospital (Moscow) in the period from January 1, 2012 to April 30, 2017 with a confirmed diagnosis of cerebral stroke/transient ischemic attack.

Results. During the first year after the CVA, 451 (65,9%) patients visited the local clinic on their own (group 1), while 166 (24,3%) patients was consulted by house call (group 2), and 67 (9,8%) did not see the physician (group 3). Patients visited by house call were more likely to have prior coronary artery disease and stroke, and the age of men was older than in other groups. Patients who did not see a doctor were less likely to have comorbidities and disabilities, and were less likely to visit the clinic before stroke. The mortality of patients in group 3 was significantly higher throughout the entire follow-up period (55,2%, 70,1% and 77,6% at stages 1, 2 and 3 (p<0,001), respectively) than in group 2 (31,2%, 55,4% (p<0,001)) and group 1 (23,7%, 37,0% and 54,3% (p<0,001)). Mortality of patients in group 1 was lower than group 2 (p<0,05-0,01). The relative risk of death in clinic visitors was 0,450 (95% confidence interval (CI), 0,333-0,608, p<0,0001), while in those visited by a doctor at home — 0,668 (95% CI, 0,482-0,927, p<0,05). In multivariate analysis and adjustment for sex and age (relative risk (RR) of death, 0,08 (95% CI, 0,048-0,133), p<0,0001 and 1,036 (95% CI, 1,031-1,042), p<0,001, respectively), the independent contribution of the factor of clinic visits was preserved. Thus, the RR of death in visitors was 0,996 (95% CI, 0,994-0,999), p<0,001 and 0,998 (95% CI, 0,995-1,0), p<0,05.

Conclusion. The lower mortality among those visited the local clinic in the first year after CVA and among those who were visited by a doctor at home, compared with patients who were not observed, confirms the important role of medical supervision in the post-hospital period.

Aim. To develop diagnostic criteria for proximal left bundle branch block (LBBB) based on non-invasive methods and to determine the significance of these criteria in predicting the effect of cardiac resynchronization therapy (CRT).

Material and methods. To develop criteria, 58 patients (21 men, mean age, 76,1±7,1 years) with LBBB occurred immediately after transcatheter aortic valve implantation (TAVI) were included. To assess the significance of the developed criteria, the second group included 22 patients (11 men, mean age, 57,9±9,3 years) with dilated cardiomyopathy (DCM), who had indications for CRT. The effectiveness of CRT was assessed by echocardiography 6 months after implantation. All patients in the DCM group and 15 patients in the TAVI group underwent superficial epiand endocardial non-invasive mapping using Amycard 01C EP Lab (EP Solutions SA, Switzerland). Patients in the DCM group underwent contrast-enhanced cardiac magnetic resonance imaging (MRI) before device implantation.

Results. The criteria for proximal LBBB included 3 electrocardiographic features: QRS complex >130 ms in women and 140 ms in men, QSor rS-configuration in V1 lead, notch in two or more lateral leads (I, avL, V5, V6), and 2 mapping criteria: characteristic location of block line and delayed activation point. In the DCM group, the criteria were positive in 13 of 22 patients (59%). The developed criteria for proximal LBBB showed a relatively strong, significant relationship with the positive effect of CRT (сhi-square test =5,46, p=0,02, Cramer test =0,5, odds ratio (OR)=15,0, 95% confidence interval (CI), 1,32-169,9, p=0,002). An additional analysis showed that both the criteria for proximal block and CRT effect are associated with myocardial fibrosis according to MRI. In particular, intramural stria-shaped contrast accumulation in the interventricular septum leads to a change in characteristic of proximal block mapping phenomena — displacement of delayed activation point (chi-square test =13,9, p<0,001, Cramer test =0,79) and displacement or absence of conduction block lines (chi-square test =6,92, p=0,009, Cramer test =0,56) and prevents the CRT effect (OR =8,67, 95% CI, 1,05-71,57 p=0,03).

Conclusion. Proximal LBBB is only one of the factors determining the effectiveness of CRT. Proximal LBBB may mask significant myocardial structural changes that prevent the CRT success.

Aim. To evaluate the diagnostic accuracy of exercise stress echocardiography on a horizontal cycle ergometer for the detection of obstructive coronary artery disease (CAD) in patients with low-risk non-ST-elevation acute coronary syndrome (NSTE-ACS).

Material and methods. The study included 95 patients aged 53 (46;63) years (men, 58%), hospitalized in the regional vascular center with low-risk NSTE-ACS. Patients with known CAD, impaired resting left ventricular contractility were not included. During hospitalization, standard stress echocardiography on a horizontal cycle ergometer and invasive or non-invasive coronary angiography (CAG) were performed. All values of coronary obstruction ≥70% were verified by invasive CAG. The assessment of myocardial revascularization was observational.

Results. All patients had normal structural and functional cardiac parameters at rest. No adverse events were recorded during the tests. The result of stress echocardiography according to impaired local contractility (ILC) criterion was positive in 9 (16%), negative in 28 (49%), incomplete symptom-limited in 20 (35%) patients. Coronary artery stenosis ≥50%/≥70% was detected in 78/78% of cases in the subgroup with a positive result, in 29/11% — with a negative result, 30/10% — with a non-diagnostic result. The association of ILC with stenosis ≥70% was higher, with an odds ratio of 30,1 (4,9; 186,5) vs 8,5 (1,6; 46,1) for stenosis ≥50%. There were following diagnostic accuracy for stenosis ≥70%: sensitivity — 70%, specificity — 93%, positive predictive value — 78%, negative predictive value — 89%, overall accuracy — 86%.

Conclusion. Exercise stress echocardiography on a horizontal cycle ergometer in patients with low-risk NSTE-ACS patients is safe and feasible. The method has moderate sensitivity and positive predictive value and high specificity, negative predictive value and overall accuracy for the detection of anatomically significant coronary artery stenosis. In the structure of results, there is a significant proportion (35%) of symptom-limited tests incomplete due to heart rate, characterized by the lowest incidence of obstructive atherosclerosis.

Aim. To conduct a retrospective analysis of the prevalence of main risk factors for thromboembolic events (TEEs) and the prescription rate of anticoagulant therapy (ACT) in patients with atrial fibrillation (AF) and a low CHA2DS2-VASc score in certain Russian regions using artificial intelligence technologies.

Material and methods. The information was obtained from the Webiomed predictive analytics platform. The sample included 87601 patients with AF aged 18-74 years (men, 49,5%, mean age, 59,3±12,3 years, mean CHA₂DS₂-VASc score, 2,3±1,5) who received care in medical organizations in 6 constituent entities of the Russian Federation in the period from 2016 to 2019. CHA₂DS₂VASc score of 1 and 2 in a man and a woman, respectively, was regarded as a moderate risk, while score of 0 and 1, respectively, as a low risk of TEEs.

Results. There were 22337 (25,5%) patients with AF at moderate risk and 18366 (21,0%) patients at low risk of TEEs. With a moderate risk of TEEs, CHA₂DS₂-VASc score of 1 in 70,4% of cases was determined by hypertension, while in 15,7% — by age 65-74 years, in 9,0% — by heart failure, in 2,9% — by myocardial infarction and/or peripheral arterial disease, in 2,0% — by type 2 diabetes. In patients with AF and a moderate risk of TEEs, ACT was prescribed in 4927 (22,1%) patients, while with a low risk of TEEs — in 1833 (10,0%). Among patients with AF and a high risk of TEEs (n=46898, 53,5%), 1216 (24,6%) patients with ischemic stroke (IS) did not initially have a high CHA₂DS₂-VASc risk.

Conclusion. In clinical practice, among patients with AF aged 18-74 years, there are quite often individuals with CHA₂DS₂-VASc score of 1 not associated with sex. These patients need an individualized approach in ACT, which is the basis for prospective studies in order to optimize the assessment of cardioembolic IS risk, as well as to analyze the efficacy and safety of long-term ACT.

The review article discusses the issues of anticoagulant therapy in cardiovascular patients with thrombocytopenia (TP), gives the concept of ethylenediaminetetraacetic acidand heparin-induced TP. The management of patients with heparin-induced TP is analyzed in detail, which consists in the discontinuation of unfractionated and low molecular weight heparin administration with replacement to direct thrombin inhibitors (lepirudin or argatroban), fondaparinux or direct oral anticoagulants.

The authors emphasize that the anticoagulant administration to most patients with platelet count >50×109/l is possible in full prophylactic and therapeutic doses. Reducing the level of platelets to 25-50×109/l in most cases requires a reduction in the anticoagulant dose by 50%. At a platelet level of 20-25×109/l or less, anticoagulant therapy should be avoided in most patients.

In addition to the scope of anticoagulant therapy, TP also determines the choice of anticoagulant as follows: in patients with acute coronary syndrome, bivalirudin or fondaparinux are recommended, while in patients with cancer and stable TP, warfarin or direct oral anticoagulants can be prescribed. In progressive TP (if heparin-induced TP is ruled out), low molecular weight heparins should be used.

Introduction. The relationship between systemic amyloidosis and coronavirus disease 2019 (COVID-19) has not been sufficiently studied to date. This paper presents a case of the persistence of COVID-19 markers in an elderly patient with systemic amyloidosis.

Brief description. A 74-year-old patient with heart failure with preserved ejection fraction and type 2 diabetes was repeatedly hospitalized due to decompensated heart failure. Based on the data of protein electrophoresis with immunotyping, biopsy of subcutaneous fat and bone marrow, echocardiographic data, the patient was diagnosed with systemic AL amyloidosis with cardiac involvement. During hospitalizations in April, August and December 2020, positive polymerase chain reaction test for SARS-CoV-2 were obtained, while there were no clinical manifestations of infection for a long time and adequate antibody production.

Conclusion. A case report demonstrates multiple SARS-CoV-2 reinfection in a severe comorbid elderly patient, as an unfavorable prognostic factor.

Association of Cardiovascular Surgeons of Russia Russian Society of Cardiology (RSC)

Association of Pediatric Cardiologists of Russia

Russian Scientific Society of Specialists in X-Ray Endovascular Diagnostics and Treatment

All-Russian Public Organization for the Promotion of Radiation Diagnostics and Therapy "Russian Society of Radiologists and Radiologists".

Task Force members declared no financial support/conflicts of interest. If conflicts of interest were reported, the member(s) of the working group was (were) excluded from the discussion of the sections related to the area of conflict of interest.

Russian Society of Cardiology (RCS)