Formulation of the diagnosis of bronchial asthma according to gina. Gina on bronchial asthma. Airflow restriction data
Cardiovascular diseases(CVD) are responsible for almost half of all deaths on the European continent. Every year, 4.35 million people die from this pathology in 53 WHO member countries, and 1.9 million people in the European Union (EU). The structure of cardiovascular mortality is dominated by coronary heart disease (CHD), accounting for 40%. Of the 169 billion euros (an average of 372 euros per person per year) spent annually on cardiovascular diseases in the European Union countries, 27% of this amount is spent on the treatment of patients with coronary heart disease. The lion's share of the money is spent on the treatment of the most frequent and terrible complication - chronic heart failure(CHF). Note that the life expectancy of people suffering from CHF directly depends on socio-economic conditions: poor people have a 39% higher risk of death than those who are financially secure.
At one time, this determined the priorities in the expenditure of healthcare funds in the "old" countries of the European Union, which has borne fruit: the incidence and mortality from coronary heart disease is steadily declining here. The same picture is observed in the Scandinavian countries, the USA and Japan, which once led in the death rate from arterial hypertension (AH). At the same time, the number of patients with CHF is growing everywhere and progressively. What is the reason for this growth and are there opportunities for cardiologists to somehow change the situation?
Epidemiological aspects
In addition to the main reason for this growth - the aging of the population, a significant contribution, paradoxically, is made by cardiologists in the field of treating their patients. For example, a decrease in mortality from myocardial infarction (MI), an improvement in patient survival lead to an increase in the number of people with left ventricular systolic dysfunction(LV DM), which develops in the postinfarction period in 40% of patients (TRACE), and successful antihypertensive therapy in patients with arterial hypertension - in patients with left ventricular diastolic dysfunction. On the other hand, diastolic dysfunction of the left ventricle appears even faster in patients with arterial hypertension if antihypertensive therapy is inadequate, which is not uncommon. Among specialists, volatile is " halves rule', stating that ' only half of the patients know that they have arterial hypertension, half of them are being treated, and half of them are being treated effectively».
Every year in the world, out of more than 1 billion patients with arterial hypertension, 7.1 million patients die due to poor blood pressure control. In 1995, for example, in the UK, patients with newly diagnosed hypertension stopped taking antihypertensive drugs after a few months, in the USA and Spain, 84 and 85% of patients receive antihypertensive drugs, but only 53 and 27% of them effectively control blood pressure, respectively. . According to other data provided by Prof. MP Savenkov at a meeting of the cardiology section of the Moscow City Society of Therapists on October 18, 2007, in the USA, effective control of blood pressure is carried out in 30% of patients, and in Russia - only in 12%.
According to the authoritative Framingham Study, performed in the era of the absence of effective antihypertensive drugs, congestive CHF was the cause of death in 40% of patients with arterial hypertension. Subsequent observations by epidemiologists confirmed the fact of special significance arterial hypertension as a risk factor for chronic heart failure. In particular, according to the 14-year Framingham study, arterial hypertension alone or in combination with coronary heart disease preceded the clinical manifestations of chronic heart failure in 70% of cases in both men and women. With blood pressure above 160/100 mm Hg. Art. the risk of developing CHF is 2 times higher than with blood pressure below 140/90 mm Hg. Art. The attributable (population) risk of developing chronic heart failure in male patients with arterial hypertension is 39%, female - 59%. For comparison: with stable angina pectoris, it is 5 and 6%, respectively, with diabetes mellitus - 6 and 12%.
Etiopathogenetic aspects
Arterial hypertension as the main risk factor for the development of chronic heart failure is given great attention for many reasons. Back in 1991, the famous scientists V. Dzau and E. Braunwald introduced the term " cardiovascular continuum". According to this model (Fig. 1), cardiovascular diseases are a sequential chain of events: the start begins with the main risk factors(FR), which include primarily arterial hypertension, dyslipidemia, diabetes mellitus, insulin resistance and smoking. If nothing is done, for example, arterial hypertension is not treated, then sooner or later the patient may get a stroke or acquire coronary heart disease, and then the chain of terrible complications will end with the inevitable development of CHF and death.
In 2001, A. M. Dart and B. A. Kingwell described the second ("pathophysiological") continuum(Fig. 2), which is a vicious circle starting from the stage of damage to the vascular endothelium and its dysfunction - this root cause of arterial atherosclerosis. Further, the circle closes by increasing the rigidity of the walls of resistive vessels, which leads to an acceleration of the pulse wave and an increase in pulse pressure, as well as blood pressure in the aorta. As a result, endothelial dysfunction progresses, and the risk of atherothrombotic complications increases. According to this model, arterial hypertension is a key factor in accelerating the atherosclerotic process and the onset of coronary heart disease. The latter is accompanied by ischemic damage to the myocardium up to the development of MI and dysfunction of the heart muscle.
In patients with arterial hypertension, the heart is forced to adapt to working conditions against the high resistance of peripheral vessels, which spasm in response to an increase in blood pressure. Sooner or later, the wall of the left ventricle of the heart thickens, which at first is the result of its adaptation. Over time, degenerative changes appear in hypertrophied cardiomyocytes (CMC), and collagen accumulates in the interstitial spaces. Already in the early stages of arterial hypertension are formed left ventricular hypertrophy(LVH) and left ventricular diastolic dysfunction(DD LV). Even mild arterial hypertension increases the risk of LVH by 2-3 times - this is a risk factor for myocardial infarction and ventricular arrhythmias. The occurrence of dysfunction of the vascular endothelium under conditions of oxidative stress contributes to the accelerated progression of the atherosclerotic process in the vessels, including coronary ones. This creates a threat of myocardial ischemia and increases the risk of MI, which is facilitated by a decrease in perfusion of the left ventricular muscle due to the presence of its hypertrophy.
If left ventricular diastolic dysfunction is the result of high impedance loading, then left ventricular systolic dysfunction is due to volume overload. A decrease in tissue perfusion with blood is accompanied by compensatory activation of neuroendocrine systems, primarily sympathoadrenal (SAS) and RAAS. Hyperactivation of the latter accelerates the progression of chronic heart failure. Note that left ventricular systolic dysfunction occurs in 2% of the population, 50% of patients are asymptomatic, patients are not treated, which worsens the prognosis of their life.
The main drug approaches to reduce the risk of developing CHF
The guidelines of the European Society for the Study of Hypertension and the European Society of Cardiology ( www.escardio.org) emphasizes that the beneficial effect of antihypertensive therapy is due to the achieved reduction in blood pressure, regardless of the agent used, with which this reduction was achieved", and " the main classes of antihypertensive drugs - diuretics, beta-blockers, calcium antagonists (CA), angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor antagonists (ARA) - are equally suitable for both initial and maintenance therapy". At the same time, it is recognized that the effectiveness of certain classes of antihypertensive drugs may be greater in some specific groups of patients.
An analysis of the results of the 12 most significant studies on the treatment of arterial hypertension, which took into account the occurrence of chronic heart failure, showed that antihypertensive therapy reduces their risk by an average of half, while the risk of coronary heart disease - by 16%, stroke - by 38% , LVH - by 35%. The latter is of particular importance, since without previous arterial hypertension it occurs very rarely and at first has a compensatory value.
With the formation of diastolic dysfunction of the left ventricle, when the coronary reserve decreases and various kinds of arrhythmias may appear, the situation is still reversible. From the stage of the onset of systolic dysfunction of the left ventricle, remodeling of the heart muscle acquires irreversible character. Note that LVH doubles the absolute risk of myocardial infarction in the elderly(this is the most common cause of the rapid onset of left ventricular systolic dysfunction), but the highest relative risk of myocardial infarction in LVH occurs in middle-aged hypertensive patients.
P. A. Meredith and J. Ostergen, A. U. Klingbeli et al. conducted an analysis of the effectiveness of various antihypertensive drugs in terms of the effect on the mass of the left ventricle. The baseline data for the meta-analysis were the results of 80 studies (n = 3767 patients) of active treatment and 17 placebo-controlled antihypertensive therapy (n = 346 patients). It has been established that both calcium antagonists and ACE inhibitors have a more pronounced effect on LVH than beta-blockers. At the same time, increasing evidence suggests that the most effective drugs in this regard are angiotensin II receptor antagonists(CATCH; LIFE). At least today it can be said with certainty that their effect is no worse than that of ACE inhibitors. The experience accumulated by cardiologists in the treatment of patients with arterial hypertension gives reason to recommend drugs that affect the RAAS as the main strategy for regression of LVH.
In this regard, the question of therapeutic tactics is also close when patients have atrial fibrillation. The latter occurs in every third patient with CHF and carries the risk of increased mortality from cardiovascular causes, especially from cerebral stroke. According to V. Fuster et al., in such patients the risk of cerebral ischemic stroke is 2-7 times higher than in patients without atrial fibrillation. CHF is a common cause of atrial fibrillation, but with a poorly controlled heart rate, atrial fibrillation can lead to the onset and rapid progression of chronic heart failure. In patients with arterial hypertension and LVH, the risk of developing atrial fibrillation is 42% (Manitoba Follow-Up Study:). The RAAS makes a significant contribution to the occurrence of atrial fibrillation in patients with arterial hypertension, therefore, from these positions, preference should be given to ACE inhibitors (SOLVD) and angiotensin II receptor antagonists (CHARM:). It has been proven that they are able to influence the process of left atrial remodeling, the increase of which is associated with the occurrence of atrial fibrillation.
There have been reports of effective use statins for the prevention of atrial fibrillation in patients with left ventricular dysfunction, after heart surgery (ARMYDA-3), after cardioversion, as well as in the pharmacotherapy of patients with coronary heart disease. Their beneficial effect is explained from the position of influence on the process of inflammation and antioxidant effect. According to the experience of D. Amar et al., the antifibrillatory effect of statins is also manifested in patients with normal levels C-reactive protein(SRP). Note that the relationship between vascular inflammation, CRP levels and the risk of atrial fibrillation is well established.
Of the 1 billion people worldwide with hypertension, 7.1 million die every year as a result of inadequate antihypertensive therapy. Two-thirds of deaths are due to cerebral stroke, although it is well known that a decrease in SBP is only at 5 mm Hg. Art. accompanied by a decrease 14% risk of death from stroke. This seems like a simple task. It can be solved with the use of almost any of the antihypertensive drugs, such as clonidine. At the same time, the use of the latter, judging by the experience of Finnish colleagues, increases the risk of cerebral stroke. Thus, in terms of their long-term results, not all antihypertensive drugs are the same.
The most convincing data on the prevention of the risk of development and progression of chronic heart failure and its complications were obtained when used in patients with arterial hypertension. ACE inhibitors and angiotensin II receptor antagonists with organoprotective properties. All of these drugs have a "class-effect" in reducing mortality and mortality from cardiovascular causes in patients with CHF with left ventricular dysfunction; in patients who have had AMI with systolic dysfunction of the left ventricle and without it; high coronary risk; those with diabetes mellitus (DM) and kidney dysfunction. All of them are highly effective as antihypertensive drugs, although, according to recent data, they are comparable to other antihypertensive drugs in terms of their effect on the risk of cardiovascular complications in patients with arterial hypertension, which was confirmed after the completion of a number of large programs. In particular, in the THOMS, STOP-2, HANE, CAPPP, UKPDS, ALLHAT studies, no significant advantages of some antihypertensive drugs over others in terms of improving the prognosis in patients with arterial hypertension have been found.
At the same time, even ACE inhibitors are a group of heterogeneous chemical compounds, which implies different effectiveness in specific groups of patients. According to J. P. Tsikouris et al., in patients with a history of AMI with left ventricular systolic dysfunction quinapril is much more effective than enalapril in terms of reducing cardiovascular mortality, as well as the level of CRP - this is the most important marker of vascular inflammation and a predictor of the risk of coronary complications.
If a trandolapril proved to be an effective drug in improving the prognosis in patients with left ventricular dysfunction after AMI when administered at a relatively low dose, this does not automatically mean that it will be equally effective in patients without left ventricular systolic dysfunction. The fact is that the presence of systolic dysfunction of the left ventricle, as a rule, is a causative factor in the formation of a congestive form of chronic heart failure. In such patients, excessive activation of neurohumoral systems is observed, which may not be the case in persons without symptoms of left ventricular dysfunction. In this case, these doses of trandolapril may not be effective.
Within the framework of the discussed topic of this article, the conclusions of two large studies - EUROPA and HOPE, are of fundamental importance, despite the difference in design and goals. Application perindopril(EUROPA) in patients with high-risk coronary heart disease, but significantly (40-80%) less than in patients in the HOPE study with ramipril, led to a decrease in the risk of AMI by 24%, and CHF - by 39%. This result cannot be interpreted solely by the antihypertensive effect of perindopril, since only 27% of patients out of 12218 treated patients had arterial hypertension, and the decrease in SBP and DBP was 5 and 2 mm Hg, respectively. Art.
Striking data comes from the HYVET study, in which effective antihypertensive therapy ( arifon retard +/- prestarium) in elderly patients resulted in a 64% reduction in the risk of chronic heart failure. Impressive results were obtained in the HOPE study in patients who have already suffered a cerebral stroke, in individuals at very high coronary risk. Of the 9541 patients over the age of 55, approximately half of the patients suffered from arterial hypertension. Purpose ramipril led to a relatively small decrease in SBP and DBP (by 3.0 and 1.0 mm Hg, respectively), but the risk of MI decreased by 20%. At the end of the 4.5-year HOPE study, an additional 2.6-year HOPE/HOPE-TOO study was launched. Its peculiarity was the comparability of the frequency of ACE inhibitors in the groups of people who received ramipril (72%) and placebo (68%). An additional reduction in the relative risk of AMI was 19%, CHF - 27.8%, which was explained by the peculiarity of the action of the drug itself.
Extremely interesting are the data of Canadian colleagues who conducted a retrospective analysis of the one-year survival of patients with AMI in 109 hospitals in the province of Quebec who received various ACE inhibitors. Interesting from the point of view that the real result of practitioners was assessed not in selectively selected patients, as is customary in test programs, but in the population of patients in their region. The fate of 7512 patients over the age of 65 was tracked. According to the results of the analysis, it was found that the most effective in reducing mortality within one year were ramipril and perindopril. In terms of their effectiveness, the remaining ACE inhibitors were ranked as follows: lisinopril > enalapril > quinapril > fosinopril > captopril.
The adjusted ratios of risk and confidence interval (95% confidence interval) were respectively: 0.98 (0.60-1.60); 1.28 (0.98-1.67); 1.47 (1.14-1.89); 1.58 (1.10-2.82); 1.56(1.132.15). With the appointment of ramipril not earlier than 3-10 days from the onset of AMI, mortality during the first month decreased by 27%, within 15 months. - by 20%. That is, real practice has confirmed the validity of the conclusions of the two most significant programs - EUROPA on perindopril and HOPE by ramipril. Note that the data presented by Canadians fit the results of two large studies - QUIT for quinapril and PEACE for trandolapril, in which, contrary to the expected improvement in life prognosis was not obtained in people at high risk of coronary heart disease, not suffering from CHF and not having left ventricular dysfunction.
In a theoretical discussion of two groups of neuromodulators - angiotensin II receptor antagonists and ACE inhibitors - the advantages of the former are undeniable. Their pronounced organoprotective action is confirmed, for example, by the results of testing angiotensin II receptor antagonists in patients with kidney dysfunction (RENAAL, LIFE) - the target organ of patients with arterial hypertension. In real practice, neither in hypertensive patients with LVH (CATCH) nor in CHF patients (ELITE II:; Val-HeFT:), the benefits of angiotensin II receptor antagonists over ACE inhibitors have been proven. The words of the chief curator of the ONTARGET study, Canadian professor Salim Yusuf, expressed after a comparative analysis of termisartan and ramipril at the 57th Annual Scientific Session of the American College of Cardiology in Chicago (2008) can be regarded as a disappointment: “ Today, telmisartan is the only angiotensin II receptor antagonist drug that has both cardio- and vasoprotective properties, the implementation of which in a high-risk patient occurs regardless of the antihypertensive effect. In terms of protective effect, it is not inferior to ramipril».
Thus, at present, the most convincing data on the possibility of preventing the risk of chronic heart failure in patients with arterial hypertension are available from supporters of the use of ACE inhibitors. In terms of reducing the risk of developing chronic heart failure in patients with arterial hypertension, it is preferable to others perindopril and ramipril. The first proved to be effective even in such a complex category of patients as patients with arterial hypertension of senile age, that is, in persons in whom the testing of many drugs, with the exception of calcium antagonists, was unsuccessful.
Atroshchenko E. S., Atroshchenko I. E.
RSPC "Cardiology" of the Ministry of Health of the Republic of Belarus; Belarusian Medical Academy of Postgraduate Education, Minsk.
Magazine "Medical Panorama" No. 2, February 2009.
GBOU VPO SOGMA
Ministry of Health of the Russian Federation
Department of Internal Diseases No. 4.
Head cafe MD prof ess o r ASTAKHOVA Z.T.
Methodological instructions for conducting a practical lesson
with 6th year students of the Faculty of Medicine on the topic:
DIFFERENTIAL DIAGNOSIS OF MAIN SYNDROMES IN CHRONIC HEART FAILURE. TREATMENT OF CHRONIC HEART FAILURE.
(class duration 8 hours, first lesson)
Vladikavkaz - 2014 - 2015 academic year year.
Guidelines for conducting a practical lesson with 6th year students of the Faculty of Medicine on the topic:
DIFFERENTIAL DIAGNOSIS OF MAIN
SYNDROMES IN CHF. CHF TREATMENT.
Purpose of the lesson:
define the concept and classification of chronic heart failure
consider the general mechanisms of the occurrence of chronic heart failure and the main differential diagnostic signs of various types of chronic heart failure
to study modern methods for verifying chronic heart failure and determining its stage and severity.
Motivation for the relevance of the topic:
CHF is the most common cause of hospitalization of patients in cardiological hospitals (almost every second patient - 49%)
In the diagnosis of CHF is present in 92% of patients.
One-year mortality in patients with clinically severe CHF reaches 26-29%, i.e. in one year in Russia, from 880 to 986 thousand patients with CHF die.
In addition, the successes of modern medicine cause the "aging" of the population. In patients older than 65 years, the incidence of CHF reaches 10% and is the main cause of disability and mortality, significantly worsens the quality of life and requires significant financial costs.
To improve the quality of life of ball patients with CHF, early diagnosis and prevention of CHF is necessary, and in the presence of clinical manifestations, constant adequate therapy is necessary.
Determining the level of preparation of students:
The second level of knowledge: control methods - written survey (20 min)
(students should know:
The main indicators of hemodynamics
1. Final systolic volume - KSO.
2. End diastolic volume - EDV.
3. SV of blood \u003d KDO - KSO (KDO (130 ml) - KSO (60 ml) \u003d UO (70 ml).
4. EF \u003d UO / KDO (normally \u003d 0.6 or 60%).
5. Cardiac output = SV x HR (5 l/min).
6. SI=CB/S (3 l/min/sq. meter).
7. Average blood pressure = DBP + 1/3 pulse blood pressure.
8. OPSS (in a large circle) \u003d average blood pressure / CO (normally from 700 to 1600 (dynes cm) -5.
9. Contractility - the degree and speed of shortening of myocardial waves (in the clinic they are judged by EF and the speed of circulatory shortening of the fibers of the left ventricle).
the degree of distension of the heart during diastole. Depends on the amount of venous inflow to the heart and myocardial extensibility (judged by the EDV).11. Afterload - the degree of myocardial tension during systole, i.e. strength of resistance to shortening of myocardial fibers; depends on the pressure and volume of the cavity, the thickness of the LV wall at the time of opening of the aortic valve.
CHF (definition of VNOK)
A disease with a complex of characteristic symptoms (shortness of breath, fatigue, decreased physical activity, edema, etc.), which are associated with inadequate perfusion of organs and tissues at rest or during exercise, and often with fluid retention in the body. The root cause is a deterioration in the ability of the heart to fill or empty, due to damage to the myocardium, as well as an imbalance of vasoconstrictor and vasodilatory neurohumoral systems.
Classification of the causes of HNK development(according to N.M. Mukharlyamov, 1987)
I. Damage to the heart muscle(myocardial insufficiency):
a. primary (myocarditis, DCMP);
b. secondary (atherosclerotic and post-infarction cardiosclerosis, hypo- or hyperthyroidism, heart damage in systemic connective tissue diseases, myocardial toxic-allergic lesions).
II. Hemodynamic overload of the heart muscle:
a. pressure (stenosis of the mitral, tricuspid valves, the mouth of the aorta and pulmonary artery, hypertension of the pulmonary or systemic circulation);
b. volume (valvular heart failure, intracardiac shunts);
in. combined (complex heart defects, a combination of pathological processes leading to pressure or volume overload).
III. Violation of diastolic filling of the ventricles:
a. Adhesive pericarditis
b. Restrictive cardiomyopathy.
The most common cause of CHF is ischemic (coronary) heart disease (CHD) - 60%. In second place are valvular heart disease (14%), followed by dilated cardiomyopathy (11%). A single cardiovascular continuum, or the continuous development of cardiovascular diseases - from risk factors to patient death.
CARDIOVASCULAR CONTINUUM
Risk factors, the main of which must be recognized as hypertension, dyslipidemia and diabetes, provoke the development of coronary artery disease, which can be complicated by AMI. As a result, contractile elements are lost, LV remodeling develops, then CHF and the patient dies. The second scenario after AMI and with developed CHF is an arrhythmic, sudden death of the patient. Shorter links are also possible, for example, from hypertension to LV hypertrophy, its dysfunction, and then to CHF. From the chronic form of IHD to myocardial hibernation, the same LV dysfunction and decompensation.
CHF classification.
Classification by V.Kh. Vasilenko and N.D. Strazhesko (1935):
STAGE I - initial, latent circulatory failure, manifested only during exercise (shortness of breath, palpitations, excessive fatigue). At rest, these phenomena disappear. Hemodynamics is not disturbed.
STAGE II - severe prolonged circulatory failure, hemodynamic disturbances (stagnation in the pulmonary and systemic circulation) are expressed at rest.
period A - signs of circulatory failure at rest are moderately expressed. Hemodynamic disturbances in only one of the sections of the cardiovascular system (in a large or pulmonary circulation).
period B - the end of a long stage, pronounced hemodynamic disturbances, in which the entire cardiovascular system is involved ( and big, and pulmonary circulation).
STAGE III - final, dystrophic with severe hemodynamic disturbances, persistent changes in metabolism and irreversible changes in the structure of organs and tissues.
period A - characterized by pronounced signs of CHF at rest, the presence of common decompensation phenomena in two circles of blood circulation and hemodynamic disorders. However, with active complex therapy, it is possible to significantly eliminate the severity of stagnation, stabilize hemodynamics, and gradually restore the functions of vital organs.
period B - irreversible changes.
Functional classification of CHF (1964):
I FC - the patient does not experience restrictions in physical activity. Ordinary exercise does not cause weakness (lightheadedness), palpitations, shortness of breath, or anginal pain.
II FC - moderate limitation of physical activity. The patient feels comfortable at rest, but the performance of ordinary physical activity causes weakness (lightheadedness), palpitations, shortness of breath, or anginal pain.
III FC - a pronounced limitation of physical activity. The patient feels at rest, but less than usual physical activity leads to the development of weakness (lightheadedness), palpitations, shortness of breath or anginal pain.
IV FC - the inability to perform any load without the appearance of discomfort. Symptoms of heart failure or angina syndrome may manifest
Thus, the functional classification of CHF reflects the ability of patients to perform physical activity and outlines the degree of changes in the functional reserves of the body, which is especially important when assessing the dynamics of the patient's condition.
The main reasons for the development of CHF
(N.M. Mukharlyamov, 1978; B.A. Sidorenko, D.V. Preobrazhensky, 1995):
1. Myocardial damage (mainly systolic insufficiency):
myocarditis;
dilated cardiomyopathy;
myocardial dystrophy;
IHD (atherosclerotic and post-infarction cardiosclerosis)
2. Pressure overload (systolic);
arterial hypertension (systemic and pulmonary);
aortic stenosis (subvalvular, valvular, supravalvular)
Narrowing of the pulmonary artery
3. Volume overload (diastolic):
aortic or mitral regurgitation;
ventricular septal defect
open ductus arteriosus
4. Combined overload.
5. Violation of diastolic filling of the ventricles (diastolic insufficiency):
hypertrophic cardiomyopathy;
Restrictive cardiomyopathy;
hypertensive heart (in the absence of LV dilatation);
isolated mitral stenosis;
pericarditis (exudative and constrictive).
6. Conditions with high cardiac output:
thyrotoxicosis;
Anemia
massive obesity;
· cirrhosis of the liver.
Principles of diagnosing CHF
Presence of characteristic clinical symptoms of HF (mainly dyspnea, fatigue, limitation of physical activity, and swelling of the ankles)
Objective evidence that these symptoms are associated with damage to the heart, and not any other organs (lungs, anemia, kidney failure)
In doubtful cases confirms the diagnosis positive response to treatment
Topic "What is the cardiovascular continuum (CVC), and how to support patients at each of its stages?" (continuum - lat. "continuous." - Approx. Aut.) was the reason for the discussion at the meeting of the press club "AZbook of Pharmacy". CVD is an ongoing chain of cardiovascular events, ranging from risk factors to chronic heart failure.
The experts presented a new perspective on the problem of high cardiovascular morbidity and mortality. The following conditions are also considered - dyslipidemia, arterial hypertension, acute coronary syndrome, chronic heart failure. At each stage of the SSC in Russia, there are specific problems that require close attention. Options for solving these problems, which will significantly reduce the mortality rate from cardiovascular causes, and the total statistics of deaths from heart and vascular diseases in the world and Russia, were presented by the Deputy General Director of the Federal State Budgetary Institution "Russian Cardiology Research and Production Complex" of the Ministry of Health of Russia, Vice President of the Russian Society of Cardiology, Doctor of Medical Sciences, Prof. Yuri Aleksandrovich Karpov:
— Cardiovascular diseases are the number one problem of the modern world community. According to Rosstat data for 2011, in the structure of causes of human mortality, 56.7% are diseases of the circulatory system (CVD). Among them, coronary heart disease (CHD) accounts for 51.9% (7.2 million people die from CHD every year, making this disease the leading cause of death worldwide); for cerebrovascular diseases (for example, stroke) - 32.3%, myocardial infarction - 5.8%; the proportion of other cardiovascular diseases is 10%. So, coronary artery disease is the main cause of death worldwide. In second place is cerebrovascular disease, in third is lower respiratory tract infections, in fourth is chronic obstructive pulmonary disease (COPD), in ninth is traffic accidents, in 12th is diabetes, in 13th is heart disease in arterial hypertension (the last two are seven times less common than coronary artery disease).
The total number of patients with coronary artery disease in the Russian Federation in the period from 2000 to 2011 increased from 5437 million to 7411 (a jump from 2003 to 2006), and with a first diagnosis it increased from 472 to 738 (a jump in 2006).
If we compare the dynamics of the number of deaths from diseases of the circulatory system in the Russian Federation in 2003 and 2011, it can be noted that it decreased by 19%. From coronary artery disease - by 10.4%. Mortality from myocardial infarction increased by 1.9% (from the primary decreased by 1.9%, from the secondary increased by 12.2%). The number of deaths from cerebrovascular diseases decreased by 31.7%. But the death rate from strokes decreased by 70% by 2001!
The main risk factors for cardiovascular disease (CVD) are as follows: age, male gender, family history of coronary artery disease (unmodified) and dyslipidemia (lipid metabolism disorder, the leading manifestation of which is an increase in the concentration of cholesterol in the blood plasma and especially in LDL. — Note ed. .), smoking, diabetes mellitus, hypertension (modified).
Life expectancy in Russia and in the world is very contrasting. Iceland leads with 81.2 years. Switzerland - 80.8 years, Spain - 80.4 years, Sweden and Italy - 80.1 years, Turkey - 68.7 years, Moldova - 68.6 years, Ukraine - 67.7 years, Kazakhstan - 66.2 years , Russian Federation — 65.4 years.
Here is a study of mortality in seven countries, depending on the level of cholesterol. There were only 3 to 10 deaths per 1000 men studied in Serbia (at low cholesterol units, 3 to 5 mmol/l). In Japan - 5 deaths (with the same units of cholesterol). In Southern Europe (Mediterranean) - from 3 to 8 deaths (at 4-6.5 mmol / l). In Southern Europe (continental) - from 7 to 10 deaths (with the same units). In the USA - from 10 to 25 deaths (at 4.75-7.75). In Northern Europe - from 15 to 30 deaths (with the same indicators).
The prevalence of arterial hypertension (AH) in Russia is high: 40% (142 million people) of the adult population (women - 40.5%, men - 38%) have elevated blood pressure numbers (BP> 140/90 mm Hg), but only 81% are aware (women - 83%, men - 78%). 66% are treated (women - 67%, men - 62%), 24% are under constant control (women - 27%, men - 18%).
The ACS register (acute coronary syndrome) contains anamnestic data on diseases preceding the development of ACSspST (more than 130 thousand cases). The frequency of diseases as a percentage is as follows: AH — 83.9; IHD - 46.7; previous myocardial infarction (MI) — 22.4; chronic heart failure (CHF) — 38.7; diabetes mellitus type II - 17.4; ischemic stroke/AST — 8.4; chronic lung diseases — 9.0.
The cardiovascular continuum is presented as a sequence of pathological events. For example, arterial hypertension, dyslipidemia, insulin resistance, smoking lead to endothelial dysfunction. She, in turn, leads to atherosclerosis. Further, the chain is as follows: coronary artery stenosis (CHD) - myocardial ischemia - coronary thrombosis - myocardial infarction - arrhythmia and loss of muscle fibers - heart remodeling - ventricular dilatation - congestive heart failure - end-stage heart disease.
According to Russian clinical and epidemiological studies COORDINATA, OSCAR, PREMIERA, PERSPECTIVE (17,326 patients), in 2004, statins were taken by 5.3% of men and 9.6% of women; - respectively 13.5 and 10.9. In 2009, the percentage increased - respectively 85.7 and 69.5.
Inpatient drug therapy for patients with ST-ACS (ACS registry) consisted of taking beta-blockers (from 2009 to 2012 — from 86.4 to 89.0%); intravenous beta-blockers, respectively, from 5.6 to 8.9%; ACE inhibitor / ARB - from 78.5 to 83.0%; statins - from 65.5 to 89.3%.
The percentage of patients who reached the target level of LDL-C during statin therapy: very high risk (1.8 mmol / l) - 12.2%; high risk (2.5 mmol/l) — 30.3%, moderate risk (3 mmol/l) — 53.4%.
The study was conducted under the auspices of the All-Russian Scientific Society of Cardiology (VNOK) and the National Society for the Study of Atherosclerosis Problems (NOA). Acad. RAMS R.G. Oganov and corresponding member. RAMS V.V. Kukharchuk. 161 doctors from 8 cities of the Russian Federation took part in DYSIS-RUSSIA: Moscow, St. Petersburg, Kazan, Krasnodar, Samara, Yekaterinburg, Tyumen, Surgut.
These results suggest the need for multipurpose strategies to influence lipid metabolism parameters using the possibilities of combined lipid-lowering therapy (statin + ezetimibe).
The concept of Russia's demographic policy until 2025 is as follows:
- stage 1. 2007-2010: population - 141.9 million people. Average life expectancy - 69 years (in 2006 - 66.9 years);
- stage 2. 2011-2015: population - 142-143 million. Average life expectancy - 71 years;
- stage 3. 2016-2025: population - 145 million. Average life expectancy - 75 years.
As a summary, I will cite the optimistic health care targets of the Russian Federation for the period up to 2020. Mortality from coronary artery disease will decrease from 397 thousand (2011) to 291 (2020). Mortality from cerebrovascular diseases is 232.8-170.5. Hospital lethality of victims of traffic accidents - from 4.4 to 3.9%. Mortality from traffic accidents in trauma centers - from 7.8 to 5.1%. The one-year lethality of patients with malignant neoplasms will decrease from 27.4 to 21.0%.
Possible application points to improve the situation:
- Despite physicians realizing that more than half of patients do not achieve or maintain LDL-C targets, only 60% of them recommend lipid monitoring once every three months or more (as recommended until targets are reached).
- A low percentage of patients receive medium and high doses of statins (eg, only 15.8% of patients treated with simvastatin were taking 40 mg; 16.8% of those receiving rosuvastatin were taking 20 mg, and 44.9% of those receiving atorvastatin were taking low and very low doses) .
- Adherence of patients to therapy, tk. Regular daily drug intake is a positive predictor of achieving target LDL-C levels.
So, a more pronounced decrease in LDL cholesterol (the lower the better) means an additional reduction in the risk of cardiovascular events. One of the most important tasks associated with reducing mortality from cardiovascular diseases is the effective correction of risk factors. This can be achieved not only in the cardio center, but also in the clinic, if the therapist attends educational programs. It is prevention that can not only stop the movement of the patient along the cardiovascular continuum, but also prevents him from entering this path.
Here is a saying: "There is such a sequence: lies, blatant lies and statistics." If the latter is "lying", then you still need to listen to it!
The report continued Yunona Khomitskaya,Head of Medical Advisors Group for Cardiology at AstraZeneca Russia:
“As one of the world leaders in the field of cardiovascular disease therapy, AstraZeneca strives not only to improve the treatment of already developed complications, but also to improve the quality of primary and secondary prevention. By conducting observational epidemiological studies, supporting registries and holding expert advice, we identify problem areas in domestic healthcare. Based on the information received, we propose possible solutions in the course of scientific exchange and various educational events. This year marks the 100th anniversary of the founding of Astra, which later became part of AstraZeneca, and all this century we have been working in the field of cardiology, developing innovative drugs and supporting research activities.
One of AstraZeneca's cardiology projects this anniversary year stands out in particular: the Fortress of Our Health project, which provided over 1,700 cardiologists and internists in 15 cities with information on modern approaches to prevention and treatment in cardiovascular disease. continuum and get to know the history of the company and its innovations.
Another example of the company's activity in the field of cardiology is the program "Your health is the future of Russia". It was initiated in 2011 by AstraZeneca. The goal of the project is to reduce cardiovascular morbidity and mortality in the Russian Federation, actualize the problem of diseases of the circulatory systems and the need for early identification of risk factors among the population, as well as the actualization of medical examinations and prevention. The project covers 21 cities of Russia.
Bronchial asthma
overview of some major changes
N.M. Nenasheva
The article is devoted to the new version of the consensus "Global Initiative for Asthma" (GINA 2014), which contains changes and significant additions in comparison with the previous consensus documents, which, according to the editors, are of great clinical importance for the practitioner.
Key words: bronchial asthma, stepwise therapy, GINA.
Introduction
Bronchial asthma (BA) is still a global health problem worldwide. The prevalence of asthma began to increase sharply from the mid-1960s in Western Europe and North America, and from the mid-1980s in Eastern Europe. In this regard, in 1993, at the initiative of the National Heart, Lung and Blood Institute of the United States and the World Health Organization, a working group was created from the world's leading experts involved in AD. The result of the activities of this group was the program "Global strategy for the treatment and prevention of bronchial asthma" (Global Initiative for Asthma, GINA), designed to develop interaction between doctors, medical institutions and official authorities in order to disseminate information about approaches to the diagnosis and treatment of asthma, as well as in order to ensure that the results of scientific research are incorporated into the standards of asthma treatment. Since 2002, the report of the GINA working group (assembly) has been revised annually (published on the website www.ginasthma.org). Many national recommendations for the diagnosis and treatment of asthma, including the recommendations of the Russian Respiratory Society (RRS), are based on the principles of GINA. This article is devoted to the new version of GINA 2014, which contains changes and significant additions in comparison with previous reports, which
I Natalia Mikhailovna Nenasheva - Professor, Department of Clinical Allergology, Russian Medical Academy of Postgraduate Education, Moscow.
rye, according to the editors, are of great clinical importance for the practitioner. Within the framework of one article it is impossible to equally cover all the changes, so we hope that this edition of GINA will be translated into Russian. In addition, this article will not discuss the sections on the diagnosis and treatment of asthma in children, since the author is not a pediatrician, but such problems as the combination/crossover syndrome of asthma-chronic obstructive pulmonary disease (COPD) and exacerbation of asthma, separate articles will be devoted.
The main changes in GINA 2014 are:
Disease definitions;
Confirmation of the diagnosis of asthma, including in patients already receiving treatment;
Practical tools for assessing symptom control and risk factors for adverse asthma outcomes;
An integrated approach to asthma therapy, recognizing the primary role of inhaled glucocorticosteroids (IGCS), but also providing individualized therapy taking into account patient characteristics, risk factors, patient preferences and practical aspects;
Emphasis on the maximum benefit that can be obtained from available drugs with the correct technique of their use and adequate adherence to treatment, which avoids the increase in the volume (step up) of therapy;
The continuum of management of a worsening asthma patient is from self-management using a written asthma action plan to primary care or, if necessary, emergency care.
Table 1. Differential diagnosis of asthma in adults, adolescents and children 6-11 years of age (adapted from GINA 2014, Box 1-3)
Age Condition Symptoms
6-11 years Chronic upper airway cough syndrome (nasal drip syndrome) Bronchiectasis Primary ciliary dyskinesia Congenital heart disease Bronchopulmonary dysplasia Cystic fibrosis Productive cough, sinusitis Heart murmurs Preterm labor, symptoms from birth Excessive cough and mucus production, gastrointestinal symptoms
12-39 years old Chronic cough syndrome associated with the upper respiratory tract (nasal drip syndrome) Vocal cord dysfunction Hyperventilation, respiratory dysfunction Bronchiectasis Cystic fibrosis Congenital heart disease α1-antitrypsin deficiency Foreign body inhalation Sneezing, nasal itching, nasal congestion, desire to "clear throat" Shortness of breath, wheezing (stridor) Dizziness, paresthesias, feeling short of breath, desire to breathe Recurrent infections, productive cough Excessive cough and mucus production Heart murmurs Shortness of breath, family history of early emphysema Sudden onset of symptoms
40 years and older Vocal cord dysfunction Hyperventilation, respiratory dysfunction COPD Bronchiectasis Heart failure Medication-related cough Pulmonary parenchymal disease Pulmonary embolism Central airway obstruction Shortness of breath, wheezing (stridor) Dizziness, paresthesia, feeling short of breath, desire to breathe Cough , sputum, dyspnea on exertion, smoking or exposure (inhalation) to harmful agents Recurrent infections, productive cough Dyspnea on exertion, non-productive cough, watch glass nail changes watch-glass phalanges Sudden onset of dyspnea, chest pain Shortness of breath, no response to bronchodilators
Designations: ACE inhibitors - angiotensin-converting enzyme inhibitors.
Strategies for effective adaptation and implementation of GINA recommendations for various health systems and socioeconomic settings, as well as for affordable medicines, have been revised. In addition, GINA 2014 includes two new chapters: Chapter 5 on the diagnosis of asthma, COPD and asthma-COPD overlap syndrome (ACOS) and chapter 6 on the diagnosis and treatment of asthma in children.<5 лет. Внесены существенные изменения в структуру и макет отчета, появились новые таблицы и блок-схемы для лучшей доступности ключевых положений в клинической практике. С целью оптимизации доклада, улучшения его практической полезности исходная информация, ранее включавшаяся в конечный документ, в настоящей версии включена в приложения, доступные на сайте GINA (www.ginasthma.org) .
This chapter includes the definition, description and diagnosis of AD. This section applies to adults, teenagers, and children 6 years of age and older. Update
A loose definition of the disease is as follows: Asthma is a heterogeneous disease, usually characterized by chronic inflammation of the airways. It is defined by a history of respiratory symptoms such as wheezing, dyspnoea, chest congestion, and cough that vary in time and intensity and present with variable airway obstruction. This definition, adopted by expert consensus, highlights the heterogeneity of AD in relation to different phenotypes and endotypes of the disease. For the first time in the OSA, AD phenotypes are presented, which can be quite easily identified:
Allergic AD: The most easily recognizable phenotype, which often begins in childhood, is associated with a history or family history of allergic diseases (atopic dermatitis, allergic rhinitis, food or drug allergies). In patients with this asthma phenotype, induced sputum examination before treatment often reveals eosinophilic airway inflammation. In patients with an allergic phenotype
Bronchial asthma
Table 2 Assessment of asthma in adults, adolescents and children 6-11 years of age (adapted from GINA 2014, Box 2-1)
1. Assessing asthma control - symptom control and future risk of adverse outcomes
Assess symptom control over the last 4 weeks
Identify risk factors for asthma exacerbation, fixed airway obstruction, or drug side effects
Measure lung function at diagnosis/beginning of therapy, 3-6 months after initiation of treatment with drugs for long-term control of asthma, then periodic measurements
2. Evaluation of treatment
Document the current stage of therapy
Check inhalation technique, treatment adherence and medication side effects
Check for an individualized written asthma action plan
Ask about the patient's attitude to therapy and his goals for treating asthma
3. Assessment of comorbid conditions
Rhinitis, rhinosinusitis, gastroesophageal reflux disease, obesity, sleep apnea, depression, and anxiety may exacerbate symptoms, reduce quality of life, and sometimes worsen asthma control
AD usually has a good response to ICS therapy;
Non-allergic asthma: some adults have asthma that is not related to allergies. The profile of airway inflammation in patients with this phenotype may be neutrophilic, eosinophilic, or small granulocytic. These patients often have a poor response to ICS;
Late-onset asthma: Some patients, especially women, develop asthma for the first time in adulthood. These patients are more likely to be allergic, require higher doses of inhaled corticosteroids, or are relatively refractory to glucocorticosteroid (GCS) therapy;
Asthma with fixed airway obstruction: Patients with a long history of asthma may develop fixed airway obstruction, which appears to be due to remodeling of the bronchial wall;
Asthma in obese patients: Some obese patients with asthma have severe respiratory symptoms and mild eosinophilic inflammation.
Information on the prevalence, morbidity, mortality, social and economic burden of AD has been moved to the appendix to Chapter 1, and factors predisposing to the development of AD, pathophysiological and cellular mechanisms of AD are given in the appendices to Chapters 2 and 3.
Further, Chapter 1 of the OSHA 2014 presents the principles and methods of diagnosing asthma, a flowchart for diagnosing newly diagnosed asthma, and diagnostic criteria for asthma in adults, adolescents, and children >6 years of age. The Federal Clinical Guidelines of the RPO for the Diagnosis and Treatment of AD have recently been published, in which, from the standpoint of evidence-based medicine, the issues of diagnosing AD are considered in detail.
corresponding to the data given in OSHA 2014.
The table of differential diagnosis of BA in adults, adolescents and children aged 6-11 years, presented in the same chapter (Table 1), is of undoubted practical importance.
The second chapter is devoted to the assessment of asthma, which includes a control assessment, consisting of two equivalent domains (a concept proposed in OHA 2009): symptom control (formerly called "current clinical control") and an assessment of future risks of adverse outcomes (exacerbations, fixed obstruction), also including assessment of treatment-related factors such as inhalation technique, adherence to therapy, drug side effects, and comorbid conditions.
Assessing asthma control
In table. 2 presents an assessment of BA in adults, adolescents and children aged 6-11 years.
This chapter provides tools for assessing the control of asthma symptoms in adults, adolescents and children 6-11 years old, which are special questionnaires and scales that allow you to determine different levels of asthma control.
Simple screening tools: Can be used in primary care to quickly identify patients in need of more detailed assessment. An example of such a tool is the Royal College of Physicians questionnaire, which consists of three questions about sleep disturbance, daytime symptoms, and activity limitation due to asthma in the previous month. The 30 second asthma test also includes an assessment of missed work/school days due to asthma. These questionnaires are not currently approved and are not used in our country.
Table 3 GINA assessment of asthma control in adults, adolescents and children (adapted from GINA 2014, Box 2-2)
A. Control of asthma symptoms
Patient's indicators for the last 4 weeks Asthma control level
well controlled partially controlled uncontrolled
Daytime symptoms more than twice a week YES □ NO □ None of the above 1-2 of the above 3-4 of the above
Night awakenings due to AD YES □ NO □
Need for symptomatic medication more than twice a week YES □ NO □
Any activity restriction due to AD YES □ NO □
B. Risk factors for adverse outcomes
Risk factors should be assessed from the time of diagnosis and periodically, especially in patients with exacerbations. FEV1 should be measured at the beginning of therapy, after 3-6 months of treatment with drugs for long-term control in order to determine the best personal pulmonary function of the patient, then periodically to continue risk assessment
Potentially modifiable independent risk factors for asthma exacerbations: uncontrolled symptoms excessive use of SABA (>1 inhaler 200 doses/month) poor adherence to treatment; poor inhalation technique low FEV1 (especially<60% должного) существенные психологические или социально-экономические проблемы контакт с триггерами: курение, аллергены коморбидные состояния: ожирение, риносинуситы, подтвержденная пищевая аллергия эозинофилия мокроты или крови беременность Другие важные независимые факторы риска обострений: интубация или лечение в отделении интенсивной терапии по поводу БА >1 severe exacerbation in the past 12 months The presence of one or more of these factors increases the risk of exacerbations, even if symptoms are well controlled
Risk factors for fixed airway obstruction No or insufficient therapy with ICS Exposure to tobacco smoke, harmful chemicals, occupational agents Low baseline FEV1, chronic mucus hypersecretion, sputum or blood eosinophilia
Risk factors for the development of unwanted side effects of drugs Systemic: frequent use of systemic corticosteroids; long-term use of high doses of ICS or the use of potent ICS; use of cytochrome P450 inhibitors Local: use of high doses of ICS or strong ICS, poor inhalation technique
Designations: SABA - short-acting β-agonists, FEV1 - forced expiratory volume in 1 second.
Definitive Symptom Control Assessment Instruments: An example is the expert consensus assessment of symptom control in the OSA. OHA 2014 experts recommend using this classification of asthma symptom control together with an assessment of the risks of exacerbations, development of fixed bronchial obstruction and side effects of drug therapy (Table 3) in order to make the right choice of treatment.
Symptom Control Numerical Instruments: These instruments provide a specially designed asthma symptom scoring system to measure good, borderline or poor control.
absence. These tools include, first of all, such validated questionnaires as the AST control test (Asthma Control Test) and the BA control questionnaire - ACQ (Asthma Control Questionnaire), approved, well-known and actively used by medical specialists in our country. There are special versions of these questionnaires designed for children. Numerical controls are more sensitive to changes in symptom control than categorical instruments.
Much attention is paid to assessing the risk of adverse outcomes of BA (exacerbations, fixed obstruction, and side effects of medication).
Bronchial asthma
karst, see table. 3), because the indicator of the level of control of asthma symptoms, although it is an important predictor of the risk of exacerbation, is nevertheless insufficient for a full assessment of asthma. Asthma symptoms can be controlled with placebo or sham treatment, incorrect (isolated) use of long-acting β-agonists (LABA), which do not affect inflammation; respiratory symptoms may occur due to other diseases or conditions, including anxiety and depression; some patients may have mild symptoms despite low lung function. Experts stress that indicators of asthma symptom control and exacerbation risk should not simply be summed up, as poor symptom control and exacerbation may have different causes and require different therapeutic approaches.
The role of lung function in assessing asthma control is essential, although studies in adults and children show that lung function does not correlate strongly with asthma symptoms. However, low forced expiratory volume in 1 second (FEVh), especially<60% от должного, является строгим независимым предиктором риска обострений и снижения легочной функции независимо от частоты и выраженности симптомов. Незначительные симптомы при низком ОФВ1 могут свидетельствовать об ограничениях в образе жизни или сниженном восприятии бронхиальной
obstruction. A normal or high FEV1 in patients with frequent respiratory symptoms may indicate other causes of these symptoms (heart disease, gastroesophageal reflux disease, or nasal drip syndrome, see Table 1). Persistent reversibility of bronchial obstruction (increase in FEV1 by > 12% and > 200 ml from basal) in patients taking drugs for long-term control, or using short-acting β-agonists (SABA) for 4 hours, or using LABA for 12 hours, indicates uncontrolled asthma.
It is noted that spirometry cannot be adequately performed in children under 5 years of age or even older, so it is less useful in them than in adults. Many children with uncontrolled asthma have normal lung function between exacerbations.
With regular ICS therapy, FVC improves within a few days and reaches a plateau after an average of 2 months. The average decrease in FEV1 in non-smoking healthy adults is 15-20 ml/year, however, some patients with asthma may experience a more pronounced decrease in lung function and even develop fixed (not completely reversible) airway obstruction, the risk factors of which are presented in Table 1. 3 .
Peak expiratory flow (PEF) measurement is recommended at the start of therapy to assess response to treatment. Pronounced variations in PSV indicate suboptimal asthma control and an increased risk of exacerbation. Long-term monitoring of PEF is recommended in patients with severe asthma and in patients with impaired perception of airflow obstruction.
Assessing the severity of asthma
in clinical practice
The severity of asthma is assessed retrospectively based on the amount of therapy necessary to control symptoms and exacerbations. An assessment can be made when the patient is on long-term control therapy for several months and it is possible to reduce the amount of therapy in order to determine the minimum amount that is effective. Asthma severity is not static and can change over months and years.
How to determine the severity of asthma when a patient has been on regular control therapy for several months: mild asthma is asthma that is well controlled with step 1 and 2 therapy, i.e. with isolated use of SABA according to
needs, or in combination with low-dose ICS, or antileukotriene drugs (ALP), or cromones;
Moderate asthma is asthma that is well controlled with step 3 therapy, i.e. low-dose IGCS/LABA;
Severe asthma is asthma requiring treatment steps 4 and 5, i.e. using high doses of ICS/LABA to maintain control, or asthma that remains uncontrolled despite this therapy.
How to distinguish between uncontrolled and severe asthma?
The most common problems should be ruled out before a diagnosis of severe AD is considered:
Poor inhalation technique (up to 80% of patients);
Low adherence to treatment;
Misdiagnosis of AD;
Associated diseases and conditions;
Continued contact with the trigger.
The experts proposed an algorithm for examining a patient with poor symptom control and/or exacerbations despite treatment (Fig. 1).
This chapter on managing asthma to achieve symptom control and reduce the risk of adverse outcomes is divided into four parts:
Part A - basic principles of asthma treatment;
Part B - drugs and strategies to control symptoms and reduce risks:
Medications;
Elimination of modifiable risk factors;
Non-pharmacological treatments and strategies;
Part C - patient education, self-management skills:
Information, inhalation skills, adherence to treatment, individual asthma action plan, self-monitoring, regular check-ups;
Part D - treatment of asthma in patients with comorbid conditions and special patient populations.
The main goals of long-term therapy for AD:
Achieve good symptom control and maintain normal activity levels;
Minimizing the risk of future exacerbations, fixed bronchial obstruction and treatment side effects.
Achieving these goals requires a partnership between the patient and the
Control of symptoms and risk factors (including lung function) Inhalation technique and adherence to therapy Patient preferences
Symptoms Exacerbations Side effects Patient satisfaction
Pulmonary function
Anti-asthma
medicinal
drugs
Non-pharmacological strategies Elimination of modifiable risk factors
Rice. 2. Control-based asthma treatment cycle (adapted from GINA 2014, Box 3-2).
health botanists; Strategies for developing these relationships are given much attention in Part A.
On fig. 2 shows the AD treatment cycle based on controls. It includes evaluation of diagnosis, control of symptoms and risk factors, inhalation technique, patient adherence to treatment and patient preferences; selection of therapy (including pharmacological and non-pharmacological strategies); evaluation/response options for ongoing therapeutic measures.
The concept of control-based management of asthma proposed in the OHA 2006 is supported by the design of most randomized clinical trials: identifying patients with poor symptom control with or without risk factors for exacerbations and modifying treatment to achieve control. For many patients, symptom control is a good guideline in reducing the risk of exacerbations. At the initial stage of the use of ICS for the treatment of asthma, there was a marked improvement in symptom control, pulmonary function, a decrease in the number of exacerbations and deaths. However, with the advent of new IGCS/LABA drugs and especially new regimens for their use (IGCS/formoterol in single inhaler mode for
Present symptoms Preferred control therapy
Symptoms of asthma or the need for SABA less than 2 times a month; no awakenings due to asthma in the last month; no risk factors for exacerbations (see Table 3, section B); No exacerbations in past year No control therapy (Evidence D)*
Infrequent asthma symptoms, but the patient has one or more risk factors for exacerbations (see Table 3, section B); low lung function or exacerbation requiring systemic glucocorticosteroids in the past year, or treated in an intensive care unit Low-dose ICS** (Evidence D)*
Symptoms of asthma or need for SABA from 2 times a month to 2 times a week or awakenings due to asthma 1 time or more in the last month Low-dose ICS** (Evidence B)*
Asthma symptoms or need for SABA more than twice a week Low-dose ICS** (Evidence A) Other, less effective options: ALP or theophyllines
Asthma symptoms bother most days, or there are asthma awakenings once a week or more, especially if any risk factor is present (see Table 3, section B) Medium/high dose ICS*** (Evidence A) or low-dose ICS/LABA (Evidence A)
Onset with severe uncontrolled asthma or exacerbation Short course of oral corticosteroids and start regular control therapy with: high-dose ICS (Evidence A) or medium-dose ICS/LABA* (Evidence D)
* These recommendations reflect evidence that chronic airway inflammation may be present in asthma even when symptoms are rare; the benefit of low-dose ICS in reducing severe exacerbations in a broad population of asthma patients is known, and there are insufficient large clinical trials comparing the effect of ICS versus demand-only SABA on exacerbations in these patient populations. ** Corresponds to stage 2 (see Table 5). *** Corresponds to stage 3 (see Table 5). * Not recommended for initial therapy in children 6-11 years of age.
maintenance therapy and relief of symptoms) and the introduction of their use in patients with severe asthma, there was such a problem as the possibility of dissonance in the response regarding the control of symptoms and the impact on asthma exacerbations. Some patients, despite good symptom control, continue to develop exacerbations, and in patients with ongoing symptoms, side effects may occur when the dose of ICS is increased. Therefore, experts emphasize the importance of taking into account both domains of asthma control (control of symptoms and assessment of future risks) for choosing asthma therapy and assessing response to treatment.
With regard to alternative strategies for the selection of asthma therapy, such as the study of induced sputum and the measurement of nitric oxide in exhaled air, it is noted that at present these strategies are not recommended for use in the general population of patients with asthma and can be used (primarily sputum study) in patients with severe asthma in specialized centers.
Drugs for the treatment of asthma fall into three categories: drugs for symptom control: used for regular maintenance
treatment. They reduce airway inflammation, control symptoms, and reduce future risks of exacerbations and decreased lung function;
Symptom-relieving drugs (first aid): These are provided to all patients with asthma for use as needed, when symptoms of difficult breathing occur, including periods of worsening and exacerbation of asthma. They are also recommended for preventive use before exercise. Reducing the need for these drugs (and ideally no need at all) is an important goal and measure of success in asthma treatment;
Adjunctive therapies for patients with severe asthma: May be used when a patient has persistent symptoms and/or exacerbations despite treatment with high doses of drugs to control symptoms (usually high doses of ICS and LABA) and elimination of modifiable risk factors.
A more detailed description of drugs used to treat asthma has been moved to the Appendix to Chapter 5 (available at www.ginasthma.org).
Table 5 Stepwise approach to symptom control and minimization of future AD risks (adapted from GINA 2014, Box 3-5)
Preferred choice of control therapy Step 1 Step 2: Low dose ICS Step 3: Low dose ICS/LABA* Step 4: Medium/high dose ICS/LABA Step 5: Initiate adjunctive therapy such as anti-IgE
Other control therapy options Consider low-dose ICS Leukotriene receptor antagonists (ALPs); low dose theophylline* Medium/high dose ICS; low dose ICS + ALP or ICS + theophylline* High dose ICS + ALP or ICS + theophylline* Add low dose oral corticosteroids
Relief of symptoms SABA on demand SABA on demand or low-dose ICS/formoterol**
Remember to: educate the patient and provide information (individual asthma action plan, self-monitoring, regular check-ups) treat comorbidities and risk factors, such as smoking, obesity, depression, advise non-pharmacological treatments and strategies, such as physical activity , weight loss, measures to avoid contact with allergens and triggers consider step up if symptoms are not controlled and there is a risk of exacerbations and other adverse outcomes, but first check the correctness of the diagnosis, inhalation technique and adherence to therapy consider switching to step down if symptoms are controlled for 3 months + low risk of exacerbations Discontinuation of ICS treatment is not recommended
* For children 6-11 years of age, theophylline is not recommended and the preferred choice of control therapy in step 3 is medium-dose ICS. ** Low-dose ICS/formoterol as a symptomatic relief drug for patients who are prescribed low-dose budesonide/formoterol or low-dose beclomethasone/formoterol as a single treatment - maintenance/control and alleviation/management of symptoms.
In table. Table 5 presents the recommended stepwise therapy for asthma, the principles of which remain the same, but some additions have been made regarding the possibility of using low-dose ICS already at step 1, as well as the possibility of using the ICS/formoterol combination as a drug for relieving symptoms.
Step 1: Symptomatic drugs as needed Preferred choice: SABA as needed. Short-acting β-agonists are highly effective in rapidly relieving asthma symptoms (Evidence A), but this treatment option can only be used in patients with very rare (<2 раз в месяц) дневными симптомами короткой продолжительности (несколько часов), у которых отсутствуют ночные симптомы и отмечается нормальная функция легких. Более частые симптомы БА или наличие факторов риска обострения, таких как сниженный ОФВ1 (<80% от лучшего персонального или должного) или обострение в предшествующие 12 мес, указывают на необходимость регулярной контролирующей терапии (уровень доказательности В).
Other options. Regular therapy with low doses of ICS in addition to SABA according to
needs should be considered for patients at risk of exacerbations (Evidence B).
Other options not recommended for routine use. Anticholinergic drugs such as ipratropium, short-acting theophyllines, oral SABAs are not recommended for routine use due to their slow onset of effect, and oral SABAs and theophyllines also because of their high risk of side effects.
Rapid-acting LABA formoterol is as effective as SABA in relieving symptoms, but regular or frequent use of LABA without ICS is strongly discouraged due to the risk of exacerbations (Evidence A).
Step 2: Low-dose long-term control plus symptom-relieving drugs as needed Preferred choice: Regular low-dose ICS plus SABA as needed. Treatment with low-dose ICS reduces symptoms of asthma, improves lung function, improves quality of life, reduces the risk of exacerbations, hospitalizations, and deaths due to asthma (Evidence A).
Other options. Leukotriene receptor antagonists (ALP) are less effective than
Bronchial asthma
IGCS (level of evidence A). They can be used as initial control therapy in some patients who cannot or do not want to use ICS, in patients who report significant side effects from ICS, and in patients with concomitant allergic rhinitis (Evidence B).
In adults or adolescents with no previous control therapy, the combination of low-dose ICS/LABA as initial maintenance therapy for long-term control reduces symptoms and improves lung function compared to low-dose ICS alone. However, this therapy is more expensive and does not have a preference for reducing the risk of future exacerbations compared to ICS alone (Evidence A).
In patients with isolated seasonal allergic asthma, such as birch pollen allergy, ICS should be started immediately on symptom onset and continued for up to 4 weeks after the end of the flowering season (Evidence D).
Options not recommended for routine use. Extended-release theophyllines have low efficacy in AD (Evidence B) and are characterized by a high incidence of side effects that can be life-threatening at high doses.
Cromones (nedocromil sodium and cromoglycate sodium) have high safety but low efficacy (Evidence A), and inhalers for these drugs must be flushed daily to avoid blockage.
Stage 3: one
or two control drugs
plus a drug that relieves symptoms,
on demand
Preferred choice (adults/adolescents): low-dose ICS/LABA as maintenance therapy plus SABA as needed, or low-dose ICS/formoterol (budesonide or beclomethasone) as maintenance therapy and for symptom relief as needed.
Preferred choice (children 6-11 years old): medium doses of ICS plus SABA as needed. In our country, the vast majority of combined IGCS / LABA drugs are registered: fluticasone propionate / salmete-
rol, budesonide/formoterol, beclomethasone/formoterol, mometasone/formoterol, fluticasone furoate/vilanterol. Adding LABA to the same dose of ICS provides additional symptom reduction and improvement in lung function with a reduced risk of exacerbations (Evidence A). In high-risk patients, ICS/formoterol as a single inhaler significantly reduces exacerbations and provides the same level of asthma control at relatively low doses of ICS compared with fixed doses of ICS/LABA as maintenance therapy + SABA on demand or compared with high doses of ICS + SABA on demand (level of evidence A). The single inhaler regimen (for maintenance therapy and relief of symptoms) is registered and approved in our country so far only for the drug budesonide/formoterol.
Other options. One such option in adults and adolescents may be to increase the dose of ICS to medium doses, but this strategy is less effective than the addition of LABA (Evidence A). Other options that are also less effective than ICS/LABA are the combination of low-dose ICS with LPA (Evidence A) or the combination of low-dose ICS with sustained-release theophyllines (Evidence B).
Step 4: Two or more control drugs plus a symptom-relieving drug as needed
Preferred choice (adults/adolescents): low-dose ICS/formoterol combination as a single inhaler or medium-dose ICS/LABA plus SABA as needed.
Preferred option for children 6-11 years old: refer to a specialist for peer review and advice.
Here in the comments of the experts there is some disagreement with the main table of stepped therapy (see Table 5), which indicates the preferred option is medium / high doses of ICS / LABA, and not a combination of low doses of ICS / formoterol as a single inhaler or a combination of medium doses of ICS/LABA plus SABA as needed. Probably, the explanation for this can be found in the further commentary on step 4, which states that the choice of therapy at step 4 depends on the choice at step 3 and the technical
name of inhaler, adherence to treatment, contact with triggers, and re-confirm the diagnosis of asthma before increasing the amount of therapy.
In addition, in adults and adolescents with asthma who have had >1 exacerbation in the previous year, the combination of low-dose ICS/formoterol as maintenance therapy and for symptomatic relief is more effective in reducing exacerbations than the same doses of ICS/LABA. as permanent maintenance therapy with fixed doses or higher doses of ICS (level of evidence A). This regimen can be started with low doses of ICS/formoterol in step 3, and maintenance doses of ICS can be increased to medium doses in step 4. Also, in patients receiving low-dose fixed-dose ICS/LABA plus SABA on demand and who do not achieve adequate control, the dose of ICS in combination with ICS/LABA may be increased to a moderate dose.
Other options. The combination of high-dose ICS/LABA may be considered in adults and adolescents, but increasing the dose of ICS is generally of little additional benefit (Evidence A) and increases the risk of unwanted side effects. The use of high-dose ICS is recommended only for a period of 3-6 months when asthma control cannot be achieved with moderate doses of ICS plus LABA and/or a third drug for symptom control (ALP or sustained-release theophyllines; level of evidence B).
For medium and high doses of budesonide, efficacy can be improved by increasing the dosing frequency up to 4 times a day (Evidence B), but maintaining adherence to this regimen can be problematic. For other ICS, twice daily dosing is appropriate (Evidence D). Other options for this stage of asthma treatment in adults and adolescents that can be added to medium or high doses of ICS but are less effective than LABAs are ALP (Evidence A) and sustained release theophylline (Evidence B).
Stage 5: the highest level
therapy and/or additional treatment
Preferred choice: refer the patient to a specialist for evaluation and consideration of additional therapy. A patient with persistent asthma symptoms or asthma exacerbations despite correct inhalation technique and
good adherence to treatment at level 4 should be referred to a specialist in the evaluation and management of severe asthma (Evidence D).
Treatment options:
Anti-IgE therapy (omalizumab): may be offered to patients with moderate to severe allergic asthma that is not controlled by treatment appropriate to stage 4 (Evidence A);
Therapy based on induced sputum analysis: may be considered for patients with persistent symptoms and/or exacerbations despite high doses of ICS or ICS/LABA, treatment may be tailored based on eosinophilia (>3%) of induced sputum. In patients with severe asthma, this strategy leads to a reduction in exacerbation and / or a reduction in the dose of ICS (Evidence level A);
Bronchial thermoplasty (not registered in the Russian Federation): may be considered for some patients with severe asthma (Evidence B). Evidence of effectiveness is limited to anecdotal observations and long-term effect is unknown;
Addition of low doses of oral corticosteroids (<7,5 мг/сут по преднизолону): может быть эффективно у некоторых пациентов с тяжелой БА (уровень доказательности D), но часто связано с существенными побочными эффектами (уровень доказательности В), поэтому этот вариант может рассматриваться только для взрослых больных с плохим контролем симптомов и/или частыми обострениями, несмотря на правильную технику ингаляции и хорошую приверженность лечению, соответствующему ступени 4, и после исключения других усугубляющих факторов. Пациенты должны быть осведомлены о вероятных побочных эффектах, необходимо осуществлять тщательный мониторинг в отношении развития ГКС-индуцированного остеопороза, должно быть назначено соответствующее профилактическое лечение.
Assessment of response to treatment
and selection of therapy
How often do asthma patients need to visit a doctor? The frequency of visits to the doctor depends on the patient's initial level of asthma control, response to therapy, patient discipline and participation in treatment. Ideally, the patient should be evaluated by a physician 1-3 months after the start of monitoring treatment and then every 3-12 months. Pos-
Bronchial asthma
Table 6. Treatment volume reduction options in controlled asthma patients according to treatment volume received (adapted from GINA 2014, Box 3-7)
Step Drugs and doses received Step down options Level
evidence-based therapy
5th High dose ICS/LABA + Continue high dose ICS/LABA and reduce dose D
Oral corticosteroids oral corticosteroids
Use induced sputum test B
to reduce the dose of oral corticosteroids
Switch to oral corticosteroids every other day D
Change oral corticosteroids to high-dose glucocorticosteroids D
High dose ICS/LABA + Refer for expert advice D
Other adjunctive therapy
4th Medium/high dose Continue ICS/LABA with 50% dose reduction ICS, B
IGCS/LABA using available forms
for maintenance therapy Withdrawal of LABA leads to worsening of the condition A
Moderate doses Reduce ICS/formoterol to low dose and continue D
ICS/formoterol twice daily maintenance therapy
in single inhaler mode and for relief of symptoms on demand
High dose ICS + other Reduce ICS dose by 50% and continue B
drug of the controlling drug of the second controlling drug
3rd Low dose ICS/LABA Reduce ICS/LABA dose to once per day D
for maintenance therapy Cancellation of LABA leads to worsening of the condition A
Low doses Reduce use of ICS/formoterol as C
ICS/formoterol maintenance regimen up to once daily and continue
single inhaler on demand for symptomatic relief
Medium or high dose ICS Reduce ICS dose by 50% B
2nd Low-dose ICS Once a day (budesonide, ciclesonide, mometasone) A
Low-dose ICS or LPA Consider discontinuation of controller medications, D
only if symptoms have been absent for 6-12 months
and the patient has no risk factors for adverse outcomes
(see Table 3, section B). Provide the patient with a personalized
action plan and closely monitor
Complete cessation of ICS in adult patients A
le exacerbation, a visit should be scheduled after 1 week to assess the condition.
Increasing the volume of therapy (step up). Bronchial asthma is a variable disease, therefore, from time to time there is a need to adjust therapy by a doctor or by the patient himself:
Step up for an extended (at least 2-3 months) period: some patients may not respond adequately to initial treatment, and if the diagnosis is correct, inhalation technique is good, treatment adherence is good, trigger factors have been eliminated, and comorbidities have been controlled, treatment corresponding to a higher level (see Table 5). Response to intensified treatment should be assessed after 2-3 months. If there is no effect, you should return to the previous step and consider alternative treatment options or the need for examination and consultation with a specialist;
Step up for a short (1-2 weeks) period: the need for a short-term increase in the maintenance dose of ICS may arise during the period of viral respiratory infections or
seasonal flowering plants. The patient can carry out this increase in the volume of therapy independently in accordance with his individual action plan for asthma or as prescribed by a doctor;
Daily adjustment: in patients who are prescribed ICS / formoterol (in the Russian Federation - budesonide / formoterol) in the mode of a single inhaler, additional inhalations of budesonide / formoterol are carried out depending on the presence of symptoms against the background of constant maintenance therapy with the recommended doses of ICS / formoterol.
Reducing the volume of therapy (step down). Once asthma control has been achieved and maintained for 3 months and lung function has reached a plateau, asthma therapy can be successfully reduced in many cases without loss of disease control.
Goals of reducing the volume of asthma therapy:
Determine the minimum effective treatment required to maintain control and reduce the risk of exacerbations, which will minimize the cost of treatment and the risk of side effects;
Lack of asthma control after 3 months of therapy with optimal adherence to treatment and adequate inhalation technique
Daily symptoms of asthma and the need for SABA; nocturnal symptoms; reduced lung function
Increasing the therapy volume (step up) Decreasing the therapy volume (step down)
Rice. 3. Algorithm for the treatment of persistent BA using mometasone furoate (MF) molecule. FOR - formoterol.
Encourage the patient to continue regular medication. Patients often experiment with intermittent use of treatment to save money or avoid unwanted side effects, so it is useful to explain that the ability to use the minimum required amount of therapy can only be achieved with regular use of therapy.
Dose reductions of ICS by 25–50% at 3-month intervals are generally appropriate and safe in most patients with controlled asthma.
In table. Figure 6 presents various options for reducing the volume of therapy in patients with controlled asthma, depending on the volume of treatment received.
Thus, the majority of adult patients with persistent asthma need long-term continuous use of ICS or ICS/LABA, which dictates the need to use more modern molecules that are characterized by high efficacy, safety, convenient treatment regimen and ease of inhalation. An example of such a molecule is mometasone furoate, both as a monodrug of IGCS (Asmanex Twist-haler), and in the form of a combined preparation of IGCS / LABA - mometasone furoate / for-moterol (Senhale). The availability of different dosing options for these drugs and the availability of delivery devices equipped with dose counters
provide an opportunity to choose the optimal treatment regimen for persistent asthma of any severity in adolescents from 12 years of age and adults and allow for stepwise therapy of asthma within a single molecule (mometasone furoate), which simplifies and optimizes treatment, contributing to a higher level of disease control (Fig. 3) .
Conclusion
In the new version of the OHA 2014, chapters on the definition, assessment of asthma, including the assessment of severity and control, step therapy, emphasize the heterogeneity of this disease and indicate phenotypes, the identification of which is not difficult and may be useful for choosing therapy; emphasis is placed on the importance of assessing risk factors for adverse outcomes of asthma, which determine the amount of pharmacotherapy along with symptom control; The main principle of asthma treatment is a stepwise approach with an increase in the volume of therapy in the absence of control and / or the presence of risk factors for exacerbations and a decrease in the volume of therapy while achieving and maintaining stable control and the absence of risk factors. In general, it should be noted the more practical nature of the construction of the OHA 2014, which contains concise and understandable tables (differential diagnosis of BA, assessment of control and risk factors, choice of initial control therapy and choice of the option to reduce the volume of therapy), criteria for determining the severity of the disease in
clinical practice, comments on different options for the stepwise treatment of asthma and an algorithm of actions in the absence of control.
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