Cardiovascular events as a № 1 killer. Pharmacotherapy of coronary heart disease
Authors: Shumakov V.O. 
Published: July 2021

Background. Computed tomography studies of ancient mummies have shown that the representatives of all ancient civilizations had atherosclerosis. It is now known that the severity of atherosclerosis depends on the content of non-high density lipoprotein cholesterol (nHDL-C) and age. A detailed analysis of global statistics on mortality from cardiovascular disease (CVD) found that the mortality of Ukrainian men and women is 14 and 23 times higher than the French counterparts. However, since the beginning of the 21st century, almost all European middle-income countries have reached a decline in mortality, probably due to the implementation of programs to combat hypertension and dyslipidemia.

Objective. To describe modern pharmacotherapy of coro- nary heart disease.

Materials and methods. Analysis of the literature on this topic.

Results and discussion. A significant proportion of deaths are due to acute coronary heart disease. Long-term treat- ment of patients after myocardial infarction should include control of risk factors and lifestyle changes, antithrombotic therapy, use of b-blockers, angiotensin-converting enzyme inhibitors, mineralocorticoid receptor inhibitors, lipid-lowering therapy. Serial intravascular ultrasound studies have shown that high-intensity statin therapy has reduced the burden of atherosclerotic plaques in non-infarct-dependent arteries (from 67.5 to 58.5 %). In addition to slowing atherosclerosis, statins also increase plaque calcification and improve its stability. Medium-intensity statin therapy reduces low-density lipoprotein cholesterol (LDL-C) by 30 %, high-intensity statin therapy – by 50 %, high-intensity statin therapy in combination with ezetimibe – by 65 %, PCSK9 inhibitors – by 60 %, high-intensity statin and PCSK9 inhibitors – by 75 %, highintensity statin therapy in combination with PCSK9 inhibitors and ezetimibe – by 85 %. The FOURIER study confirmed the high efficacy of PCSK9 inhibitors in reducing LDL-C in high-risk patients. The hazard ratio for the composite endpoint (cardiovascular death, myocardial infarction, CVD hospitaliza- tion, need for revascularization) for evolocumab compared to placebo was 0.85 (p<0.0001). The ODYSSEY OUTCOMES study found similar results for alirocumab. In general, statin therapy with a decrease in LDL-C of more than 50 % and/or to a level

<1.4 mmol/L is recommended for all patients with acute coro- nary syndrome without ST segment elevation. If maximal dose of statins does not allow to reach such results in 4-6 weeks, it is recommended to add ezetimibe. In the absence of effect on the background of treatment with this combination, it is necessary to add PCSK9 inhibitors. In the context of the COVID-19 pandemic, it is necessary to continue taking all cardiac drugs, including statins. There is evidence that statins help to reduce the severity of viral pneumonia and to decrease the mortality from acute respiratory viral infections. Statins have a number of pleiotropic effects: anti-inflammatory, immunomodulatory, antioxidant, and antithrombotic. All of them are favorable for coronavirus infection. In addition to statins, in coronary heart disease it is advisable to prescribe metabolic therapy. Tivorel (“Yuria-Pharm”) is indicated for coronary heart disease, acute myocardial infarction and after a heart attack. Already on the third day of treatment of acute coronary syn- drome, the effectiveness of basic therapy in combination with Tivorel (100 ml per day) exceeds the effectiveness of basic therapy only in reducing the incidence of anginal pain by 35 % and the use of opioid analgesics in case of pain by 38 % (Vakaliuk I.P., 2015). Foreign studies confirm that L-arginine reduces the symptoms of angina and improves the quality of life of patients, reduces blood pressure and pulmonary artery pressure in patients with pulmonary hypertension. Apart from that, L-carnitine helps to increase the ejection fraction and re- duce the area of myocardial infarction, eliminate arrhythmias, reduce cardiovascular mortality. Tivorel has a beneficial effect on left ventricular remodeling. After 10 days of basic therapy in combination with Tivorel, the end systolic volume of the left ventricle in post-infarction patients is reduced by 16 %, and in the group of basic therapy – by 3 %. 32-80 % of CVD patients have mental disorders that increase the risk of death. Lodixem (“Yuria-Pharm”) is a specialized cardioprotector with a daytime tranquilizer effect. The effectiveness of Lodixem in the combined therapy of stable angina, hypertension, heart failure, acute coronary syndrome has been proven.

Conclusions. 1. Long-term therapy of patients after myo- cardial infarction should include control of risk factors and lifestyle changes, antithrombotic therapy, use of b-blockers, angiotensin-converting enzyme inhibitors, mineralocorticoid receptor inhibitors, and lipid-lowering therapy. 2. All patients with acute coronary syndrome without ST segment elevation are recommended statin therapy with a decrease in LDL-C by more than 50 % and/or to a level <1.4 mmol/L. 3. In the context of the COVID-19 pandemic, it is necessary to continue taking all cardiac drugs, including statins. 4. Tivorel reduces the incidence of anginal pain, the use of opioid analgesics for pain, and has a beneficial effect on left ventricular remodeling. 5. Lodixem (a specialized cardioprotector with the effect of a daytime tranquilizer) is effective in the treatment of stable angina, hypertension, heart failure, acute coronary syndrome.