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Experts from the MEDSI Lipid School discussed the urgent need for prevention of cardiovascular diseases.


On September 8, on the basis of the Clinical Diagnostic Center MEDSI on Belorusskaya, a scientific and practical conference "Lipid School" was held, held by the MEDSI Group of Companies together with the Russian Cardiology Society and the National Atherosclerosis Society. Due to the unstable epidemiological situation, the meeting was held online, but this did not prevent the speakers from highlighting in detail current issues in the field of cardiology and lipidology, and the audience from being as involved as possible in the process. 

leading domestic experts in the field of study and treatment of atherosclerosis, members of the board of the RSC and NOA, professors of the A. L. Myasnikov Institute of Clinical Cardiology, the State Research Center for Preventive Medicine of the Ministry of Health of the Russian Federation and the MEDSI Group.

I was the first to greet the participants < b>Gennady Alexandrovich Konovalov, Doctor of Medical Sciences, Professor, Scientific Director of the KDTSB, Head of the Center for Diagnostics and Innovative Medical Technologies, Member of the NOA, Chairman of the Academic Council of the MEDSI Group.
In his welcoming speech, the professor noted that today, in a pandemic, lipidology is of great importance. So, at the recent European Council of Cardiology, the topic of lipid metabolism disorders during infection with COVID-19 was especially acute. European doctors and scientists noted that patients with a new coronavirus infection need more careful correction of lipid levels, especially if they are diagnosed with a familial form of hyperlipidemia. 

Keeping up with their European colleagues, Russian specialists are also actively working in this direction. As an example, Gennady Aleksandrovich cited the experience of the MEDSI clinic on Belorusskaya, where the Center for Diagnosing Disorders in Patients who had a COVID-19 Coronavirus Infection and Preventing Severe Complications in Case of Infection was established. Doctors from various fields were invited to the Center, including cardiologists-lipidologists. For almost three months, 2500 patients turned there, who were provided with modern and timely assistance, including the correction of lipid metabolism and the elimination of blood clotting problems. 

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These measures are effective not only in case of infection coronavirus, but also as a prevention of cardiovascular disasters. This, in particular, was discussed by Igor Vladimirovich Sergienko, Doctor of Medical Sciences, Professor, Head of the Laboratory of Atherosclerosis Phenotypes of the Institute of Clinical Cardiology. A.L. Myasnikova Federal State Budgetary Institution National Medical Research Center of Cardiology of the Ministry of Health of the Russian Federation, director of the NOA, in his report “Modern approaches to the primary prevention of atherosclerosis.”

He noted that at the moment the situation both in our country and in the world is such that often the prevention of cardiovascular diseases and their complications is discussed when the patient has already suffered a myocardial infarction or stroke. “Many have this approach: as long as nothing hurts and nothing happens, then nothing needs to be done. And this applies to both patients and doctors. And only when the trouble happened, some measures begin to be taken, including in relation to risk factors,” said Igor Vladimirovich.

The most common risk factors include dyslipidemia, smoking, obesity, hypertension, diabetes, and family predisposition. The specialist cited statistics that show that 55% of patients who had a myocardial infarction had dyslipidemia, 40% had hypertension, 30% had obesity, and more  30% had a hereditary form of dyslipidemia, 17% had diabetes. Half of these patients smoked for a long time. And only 9% of patients with a heart attack did not have the listed risk factors.

As Igor Vladimirovich noted, all these conditions can be corrected, they can and should be fought. However, as another study showed, in most cases this does not happen. “Back in 2001, cases of heart attack in young people were analyzed. And a survey was conducted among doctors that if a month before the disaster such a patient turned to a cardiologist, would the specialist change the tactics of treatment, prescribe statins, and try to eliminate risk factors. The answer was shocking - in 75% of cases, the doctor did not change anything in therapy. And a recent similar study confirms the same statistics, ”said the professor. Accordingly, he added, it is necessary to change tactics, especially in modern conditions.

So, if we talk about coronavirus, then the doctor called obesity the most dangerous risk factor. Moreover, it must be understood that obesity and high cholesterol are not always directly proportional, on the contrary, sometimes obesity leads to a decrease in cholesterol, which, it would seem, should reduce the likelihood of a cardiovascular catastrophe. However, with this disease, there is chronic inflammation and a change in blood clotting, which also leads to the development of a heart attack. That is why it is important to consider this risk factor as an independent one.

It is possible to avoid the development of a cardiovascular catastrophe by observing the most elementary rules of primary prevention. This is, first of all, proper nutrition: a variety and abundance of vegetables in the diet, cereals, legumes, fruits, minimization of animal fats, rejection of fast carbohydrates, fatty sauces. It is important to quit smoking. Conduct screening, especially in people at risk: in patients with chronic kidney disease, with a aggravated family history, atherosclerotic lesions, obesity and prediabetes. It is also desirable to measure the level of low density lipoproteins in men over 40 years old and in women over 50 years old, since they are also at risk.

“These are all the rules known since childhood, they are very simple. And, as the practice of other states has shown, primary prevention gives a real tangible result. In North Korea, attention was paid to nutrition, in Finland, many people stopped smoking - and as a result, mortality from cardiovascular diseases has significantly decreased in both countries,” Igor Vladimirovich summed up his speech.

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However, if smoking cessation and adherence to proper nutrition are preventive measures available to everyone, then what about people with familial forms of dyslipidemia? This question was answered in his report "Hereditary dyslipidemias: etiology, diagnosis, prognosis and treatment" Aleksey Nikolaevich Meshkov, candidate of medical sciences, head of the laboratory of the Federal State Budgetary Institution National Research Medical Center for Therapy and Preventive Medicine, lipidologist.

Speech expert began by debunking the myth that hereditary diseases are very rare. Lipid metabolism disorders caused by genetic (or hereditary) abnormalities occur in every 300th inhabitant of the planet. 

“We also conducted a similar study, which involved 11 regions. And it turned out that in our country there are even more such patients — 1 in 173,” added Aleksey Nikolayevich.

However, the frequency of familial forms of dyslipidemia is 20 times higher among patients with cardiovascular diseases, coronary heart disease, acute coronary syndrome, that is, every 14–17th cardiac patient has a hereditary lipid metabolism disorder.
Among the genetic forms of dyslipidemia, monogenic and polygenic can be distinguished. In the first case, there is one defect in one gene, and this will be enough for the development of the disease. In this case, the disorder can be autosomal dominant, when parents who have a lipid metabolism disorder pass on the “broken” gene to their children, and autosomal recessive, in which case the parents are only carriers of the gene, but they themselves may not get sick.

In the polygenic form, there is a combination of many defects in different genes, and this type is the most common.
Understanding the genetic basis is of great importance in the diagnosis of the disease. In the case of dominant forms, the diagnosis is simple. “But if we are talking about a recessive disorder, then it is important not only to identify a lipid metabolism disorder in a person, but also to suspect a hereditary predisposition, since with a 50% probability, his brothers, sisters, children can also have this disease. And they should also be taken under control in order to delay the development of cardiovascular disease,” the expert added. , member of the Russian Society of Cardiology, Member of the European Society of Cardiology, Member of the Academic Council of the Medsi Group of Companies. She presented the report "Secondary prevention of cardiovascular complications in patients with hypercholesterolemia".

As Olga Nikolaevna noted, this topic would not be so relevant if both patients and doctors followed the recommendations that were voiced by Igor Vladimirovich Sergienko. However, the topic is hot: recent European data show that nearly half of all deaths are caused by diseases of the circulatory system. At the same time, if earlier men were “leading”, now the percentage of women dying due to cardiovascular pathologies has increased. At the same time, patients who once suffered a cardiovascular catastrophe fall into a high-risk group - out of 108 thousand patients who had a heart attack, every 5th patient developed a repeated cardiovascular catastrophe within a year after that. It is also known that repeated episodes are associated not only with the arteries associated with the primary infarction, but also with other vessels. That is why secondary prevention is given so much attention. And here the control of low density lipoproteins comes first - if the target values for this indicator are not reached, then the risk of developing a cardiovascular event increases by 4 times.

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Patients from the category of high and very high factors require special attention at risk are patients with atherosclerotic diseases, diabetes mellitus, severe atherosclerosis, who have had a heart attack, acute coronary syndrome, coronary operations, percutaneous interventions, aortocoronary interventions. The category of extreme risk includes patients who have suffered two or more cardiovascular events within two years. “All of these patients should reach their cholesterol targets. And here it is important to change the approach to therapy, since in 75% of cases the target value is not achieved,” says Olga Nikolaevna.

Why is such a picture observed? Firstly, according to the expert, all drugs have limited effectiveness, so it is often impossible to achieve the desired result with monotherapy. Secondly, there are severe patients with a large number of comorbid conditions, with hereditary hypercholesterolemia, in which standard therapy will be ineffective. Thirdly, many patients are not sufficiently adherent to therapy, 40% of them do not even know their cholesterol level. “It should be noted that not all doctors are interested in achieving the patient's target values. There is an opinion among some doctors that the recommendations that are being developed by the world medical community are difficult to implement. In addition, they believe that there will be too many side effects due to too low cholesterol levels,” the expert added.

The doctor calls the use of combination therapy the way out of this situation. As an example, Olga Nikolaevnatook several clinical cases when patients with a high risk factor have been observed in the clinic for almost 5 years and receive combination therapy, which also includes statins as the gold standard of treatment. And all this time they maintain the target cholesterol level.
He spoke about combination therapy in the final report “Hereditary forms of hypercholesterolemia. Refractory dyslipidemia. The experience of the Medsi lipid clinic» Gennady Alexandrovich Konovalov.

Familial hypercholesterolemia, a hereditary disorder of lipid metabolism, is a serious problem - it is widespread - it affects 34 million people worldwide, but practically is not diagnosed, undergoes insufficient treatment and leads to death. 

Gennady Alexandrovich noted that MEDSI specialists were among the first in Russia to start using a new class of drugs - PCSK9 inhibitors in the treatment of disorders lipid metabolism, which are now included in the list of vital. Long-term treatment with new drugs in combination with other methods of therapy is received by more than 1,000 patients of the Lipidology Clinic of the CDC MEDSI on Belorusskaya. The addition of a PCSK9 inhibitor to standard therapy leads not only to effective cholesterol reduction, but also to the regression of atherosclerotic lesions of the coronary arteries with a decrease in cholesterol below 1.5 mmol/L. This group of drugs has proven efficacy in lowering the most atherogenic Lp(a) in patients with familial hypercholesterolemia and established cardiovascular disease or other factors associated with a very high risk of coronary heart disease, such as a positive family history or statin intolerance.
Such an approach to therapy, based, among other things, on the correction of cholesterol levels, can significantly reduce the risk of developing cardiovascular accidents, primarily myocardial infarction.

heart attacks and other serious consequences. And even our president, not being a doctor, is already saying that it is necessary to treat so that there are no heart attacks. We at MEDSI have been working on this paradigm for a long time,” added the professor.

Now, according to Gennady Aleksandrovich, the percentage of people with elevated cholesterol levels is still high. Approximately 24% of adolescents have lipid disorders - these are the people who will face cardiovascular events in their 30s and 40s. Among those who came to see a therapist with any complaints, 80% of adult women and 79% of men, according to the ARGO study, have some kind of lipid disorder that requires correction. “And, again, it is important to remember that 30% of these patients have hereditary forms of hypercholesterolemia. And it is important to diagnose this before a catastrophe happens,” the professor added.

According to the Institute of Preventive Medicine of the Russian Federation, the total economic damage from the burden of cardiovascular pathologies is 1.5% of the country's GDP. And most of the damage is due to coronary heart disease. At the same time, 33% of patients with coronary heart disease have a high level of the most atherogenic Lp(a), which is not detected in a timely manner.

This topic is now being actively raised by the world medical community. On January 2, 2020, the Global Call to Action of the Heart Societies of 60 countries for action on familial hypercholesterolemia was issued, as 9 out of 10 such patients remain undiagnosed before the onset of the disease. If left untreated, their risk of dying from a cardiovascular event is 20 times higher. But with timely diagnosis, this can be prevented. Cardiologists around the world are unanimous in their opinion: familial hypercholesterolemia should become an urgent public health priority.

The diagnosis of familial hypercholesterolemia can be made based on three main symptoms, Gennady Aleksandrovich noted: the patient's hypercholesterolemia, hypercholesterolemia of close relatives of the first degree, history of coronary artery disease under the age of 55 and the presence of one of the symptoms: xanthomatosis, xanthelasma, lipoid corneal arch. At the same time, the diagnosis can be verified by reducing the number of LDL receptors from the proper one. Lack of timely diagnosis leads to the loss of 16-20 years of life in these patients. And it is important to start treatment from the moment of diagnosis, in fact, treatment should start from birth, especially in the case of homozygous form of hypercholesterolemia.

LDL, Gennady Aleksandrovich first of all named a change in lifestyle (motor activity, proper nutrition, giving up bad habits), statin therapy, with its insufficient effect - the addition of ezetrol. If this treatment fails, or there is resistance to previous drugs, then the use of PCSK9 inhibitors, which in recent years have been increasingly used in the treatment of lipid disorders, especially in cases of refractory dyslipidemia, comes to the fore. To achieve the best effect, it is recommended to use the LDL and Lp(a) apheresis methods, which were first used in Russia under the guidance of Professor Gennady Aleksandrovich Konovalov

The Center for Diagnostics and Innovative Medical technologies CDC MEDSI on Belorusskaya has the longest experience in Russia – more than 37 years – in the treatment of patients, including children, with hereditary (homo- and heterozygous) forms of familial hypercholesterolemia using advanced methods of therapeutic apheresis: plasmapheresis, cascade plasma filtration, LDL and Lp (a) Immunosorption, dextran sulfate plasma adsorption, HELP (heparin LDL precipitation). Among them, some of the most effective in reducing LDL-C and Lp(a) are immunosorption, cascade plasma filtration and HELP. 

Professor Konovalov, have actually received a second birth - now they are already adults with their own families, living a full life. During all this time, the specialists of the Center for Diagnostics and Innovative Medical Technologies of the CDC MEDSI on Belorusskaya have performed more than 78,000 procedures for the selective removal of atherogenic fractions, more than 17,000 patients have been successfully treated.

The doctors of the Lipidology Clinic of the CDC MEDSI on Belorusskaya have successful experience patients with familial hypercholesterolemia and the use of innovative treatment methods and note examples from clinical practice of atherosclerosis regression in the most severe refractory patients with hereditary hypercholesterolemia, including hyper Lp(a). 1500-2000 patients with dyslipidemias. Over the past 18 months of the clinic's operation, 23,000 patients with lipid metabolism disorders have been treated, of which more than 3,000 people have hyper Lp (a), which is very difficult to treat, since statins and fibrates are ineffective in this case. Patients with hyper Lp(a) make up 25% of the total number of patients observed in the clinic - and this indicator, as well as the viscosity and function of the vascular endothelium, is determined by all patients of the lipidology clinic. 

The main emphasis in treatment such patients is focused on the use of PCSK9 inhibitors and LDL and Lp(a) apheresis procedures. A significant percentage of patients in the clinic have hereditary forms of dyslipidemia: 10% - homo- and severe heterozygous form of familial hypercholesterolemia. In the CDC MEDSI on Belorusskaya, up to 80% of patients reach the target level of low-density lipoproteins, diagnosis is more than 60%. Today, more than 700-800 patients receive PCSK9 inhibitors regularly for a long time, 60% as primary prevention. Against the background of combined therapy, regression of atherosclerosis is achieved in more than 20% of patients. 

Last year alone, 180 doctors from metropolitan and regional MEDSI clinics were trained within the Lipid Schools. Lipidology rooms work in adults and in MEDSI pediatric clinics. The high level of competence of pediatric cardiologists and lipidologists makes it possible to detect hereditary disorders of lipid metabolism, including familial hypercholesterolemia, in the early stages, in children 3-4 years old.

The doctor's attention to details in the timely detection of lipid metabolism disorders, and the patient's attention to his health - will help solve this problem, said Gennady Aleksandrovich.

In conclusion of his report, the scientific director of the MEDSI Group recalled the quote from the Chinese medical tract of 2600 BC: "An excellent doctor prevents diseases, an ordinary doctor treats diseases to complications, a mediocre doctor treats complications of a disease," and wished everyone to be excellent doctors and engage in primary prevention seriously.
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