Prevention of activation of blood coagulation is a cornerstone of treatment strategies in patients with acute coronary syndrome (ACS). Medications that are used for this purpose help stop building up of blood clots in the area of damaged atherosclerotic plaque and prevent the development or recurrence of coronary artery occlusion. At the same time, the antithrombotic action should be versatile and prevent both thrombocyte and thrombotic mechanisms of blood clotting. The reduced platelet aggregation is achieved by prescription of aspirin with ticagrelor, clopidogrel or prasugrel as early as possible (and, if necessary, addition of platelet IIb/IIIa receptor blockers). Parenteral anticoagulants – unfractionated heparin (UFH), low molecular weight heparins (LMWH), fondaparinux are used to prevent the thrombin formation in the early periods of ACS. At the same time, the current clinical guidelines for the treatment of ACS with ST elevation recommend to use UFH in patients undergoing primary percutaneous coronary intervention (PCI), enoxaparin in patients receiving thrombolytic therapy with a fibrin-specific agent, and fondaparinux in streptokinase thrombolytic therapy [1]. The current guidelines for treatment of ACS without ST elevation (ACSwSTe) argue that fondaparinux should be preferred to other anticoagulants [2]. It came into use for the treatment of ACS later than any other anticoagulants, ranks higher in the ACSwSTe guidelines, and, therefore, deserves a separate discussion. 

The use of combined antithrombotic therapy in patients with atrial fibrillation who underwent percutaneous coronary interventions is associated with an increased risk of bleeding. In this regard, minimizing haemorrhagic risk is one of the strategic priorities in the management of this clinical group. The article is devoted to the discussion of strategies to reduce the bleeding risk in this category of patients. Particular attention is paid to the role of direct oral anticoagulants in the implementation of this strategy.

Prasugrel is a third-generation thienopyridine that provides earlier onset of action, has a reduced probability of insensitivity to the drug, a greater degree of inhibition of ADP-induced platelet aggregation compared to clopidogrel. Prasugrel should be proscribed to the following categories of patients: 1) patients with ST-segment elevation ACS who undergo primary percutaneous coronary interventions; 2) patients with ST-segment elevation ACS, who underwent thrombolysis, but scheduled to receive delayed PCI; 3) patients with non ST-segment elevation ACS with a known coronary anatomy, which are scheduled to receive PCI; 4) patients who had stent thrombosis due to clopidogrel resistance. Prasugrel may be considered in patients with stable coronary artery disease if they are at high risk of stent thrombosis after a planned PCI. One should avoid prescribing this drug to patients with a history of stroke or TIA, as well as to patients 75 years or older, with body weight less than 60 kg. The best results for the use of prasugrel are expected in patients younger than 60 years old, with ST segment elevation MI, concomitant diabetes mellitus, creatinine clearance of at least 60 ml / min. The article also discusses current ideas about the «de-escalation» of prasugrel therapy, presents recently published data on the comparative efficacy and safety of prasugrel and ticagrelor.

This article analyzes the frequency of polymorphisms of hemostasis system and folate cycle protein genes associated with increased risk of thrombophilia based on the results of CHGMA (Chita State Medical Academy) genetic laboratory patients with reproductive health disorders. Method of research is allele-specific PCR. It was analyzed 1800 DNA samples. The most frequently mutations occur in the genes of receptors in the platelets and the folate cycle, mostly heterozygous substitution. Leiden mutation (F5) and prothrombin mutation (F2) are the most significant in the thrombophilia development and occur much less frequently. Only in one case revealed a homozygous mutation in the gene F2 and F5.

The article presents a clinical analysis of the patient with a newly developed unprovoked episode of venous thromboembolic events. It discusses the challenges in the diagnosis of pulmonary embolism, the need for thrombolytic therapy in patients with pulmonary arterial thromboembolism of medium risk. The guidelines for diagnosis of antiphospholipid syndrome in accordance with modern principles are provided. It also considers the issues of anticoagulant treatment.

This article describes the clinical observation of a patient with an atherosclerotic aneurysm of the thoracoabdominal aorta and the occlusion of all visceral arteries. Taking into account the occlusion of all visceral arteries, we opted for a hybrid method of treatment, which included total visceral debranching followed by endoprosthetics of the thoracoabdominal aorta. The chosen method made it possible to execute an open surgery without any complications.

In the current practice, patients with atrial fibrillation receive triple antithrombotic therapy after PCI, which includes aspirin, clopidogrel and oral anticoagulant. Several clinical trials were conducted to identify an alternative strategy for antithrombotic therapy that would minimize the risk of haemorrhagic complications, including RE-DUAL PCI trial, in which the treatment regimens under test have been developed in accordance with the current guideline recommendations and requirements of real clinical practice. This trial compared the standard triple antithrombotic therapy – warfarin, P2Y12 receptor inhibitor for 12 months and aspirin (≤100 mg) for 1–3 months – and two regimens of dual antithrombotic therapy including a P2Y12 receptor inhibitor and dabigatran at one of the doses recommended to prevent stroke – 110 mg twice daily or 150 mg twice daily (for 12 months). The rates of major bleeding events in the 110 mg DE-DAT treatment arm were significantly lower as compared with the standard therapy, and the frequency of major ischemic events was insignificantly higher. In the 110 mg DE-DAT treatment arm, the rates of major bleeding events were also significantly lower, and an insignificant tendency towards reduction of ischemic events was also revealed. Thus, both regimens are equally effective, but potentially safer compared with the standard therapy, so if a particular patient has different risk ratios of ischemic and haemorrhagic events, the physician may choose the more preferable. The article also discusses practical approaches to minimizing the risk of bleeding in patients with AF who receive combined antithrombotic therapy after PCI.

Assessment of kidney function is mandatory in all cardiac patients, and patients with atrial fibrillation represent a category of patients with high thrombotic risk, which increases the risk of decreased kidney function during follow-up. Controversial issues of warfarin-associated nephropathy are important today. A prospective 5-year follow-up of 172 patients receiving warfarin therapy showed that 26.7% had the sudden loss of renal function (SLRF) (defined as an annual decline in glomerular filtration rate (GFR) ≥ 3 ml/min/1.73 cm2). Based on the results of the ROC analysis, it was determined that the maximum INR > 3.97 was associated with the SLRF (the area under the curve was 0.649, the sensitivity 56.5%, the specificity 74.6%, p = 0.003), and the maximum INR> 6.0 increased the specificity of the analysis to 96%. The study showed that for patients who had a maximum INR value ≥ 3.97, the mean delta of changes in GFR was negative, and the largest negative dynamics was characteristic for patients with a maximum INR ≥ 6.0. The estimated odd ratio of SLRF confirms the high prognostic significance of the maximum INR value. The maximum INR 3.97-5.9 increased the risk of SLRF by 3.07 times (95% CI 1.5241-6.2017, p = 0.0017), as well as the INR ≥ 6.0 (OR 3.05, 95% CI 1.0073-9.2433, p = 0.0485). The multifactorial discriminant analysis showed that the SLRF predictors against the background of 5-year warfarin therapy included the maximum INR ≥ 3.97 (F = 10.45, p = 0.0014), IHD (F = 8.7, p = 0.0036), diabetic nephropathy (F = 5.29, p = 0.0226) and the CHA2DS2-VASc score ≥ 4 (F = 5.05, p = 0.0258).

Oral anticoagulants are widely used to prevent thromboembolic events in patients following total knee arthroplasty [1]. The genetic characteristics of patients affect the efficacy and safety of anticoagulants [2]. Dabigatran etexilate is a direct inhibitor of thrombin used as a prophylaxis of venous thromboembolic events (VTE) in Europe and Russia. [3]. This study evaluated the impact of ABCB1 and CES1 genetic polymorphisms on the peak and residual dabigatran concentration in orthopedic patients. Material and methods: A total of 30 patients aged 43 to 77 years following knee joint replacement were enrolled in the study. All patients received dabigatran etexilate at a dose of 220 mg/day for the prevention of VTEO. ABCB1 and CES1 genetic polymorphism genotyping was performed by real-time polymerase chain reaction (PCR). The peak and residual concentrations of dabigatran were determined by high-performance liquid chromatography (HPLC). Results: It was found that the ТТ genotype of the MDR1 gene С3435Т polymorphism is associated with a higher peak concentration of dabigatran than the CC genotype (p <0.1). Statistically significant results for CES1 gene rs2244613 polymorphism were obtained in patients younger than 60 years (p <0.05). The analysis of the haplotypes combination in two polymorphisms showed that the most common haplotype combination CC (rs1045642) ABCB1/CT (rs2244613) CES1 was significantly associated with a higher peak concentration of dabigatran compared to the rest of haplotype combinations (p = 0.002). Conclusions: The examination of a cohort of patients receiving dabigatran for the prevention of VTE during the period of large joints arthroplasty showed that SNPs C3435T ABCB1 and rs2244613 CES1 could play an important role in changing dabigatran concentrations. No data suggestive of the impact of SNP ABCB1 rs4148738 on the peak concentration of dabigatran were received.

The review article presents data on the management of lipid storage disease in patients with diabetes mellitus (DM). A clinical case of a patient with diabetes and high cardiovascular risk caused by severe hyperlipidemia among other things is provided for illustrative purposes. The article reviews the results of clinical studies of the efficacy and safety of Pitavastatin in patients with cardiometabolic disorders. The dynamics of the lipid spectrum and glycaemia indicators against the background of course therapy with Pitavastatin at a daily dose of 4 mg in combination with the diet therapy is monitored in patients with diabetes.