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The Beers Criteria are a tool for optimizing pharmacotherapy in elderly patients, containing information on potentially inappropriate drugs, which is only advisory in nature and is not mandatory for use in Russian Federation. In the updated version of the Beers Criteria from 2023, the expert opinion on rivaroxaban has changed — instead of "use with caution", as stated in the previous document from 2019, the experts now believe that "long-term treatment with rivaroxaban in non-valvular atrial fibrillation (AF) and venous thromboembolic complications (VTE) should be avoided in favor of safer alternative anticoagulants". This statement is based on moderate-quality evidence obtained from observational studies and network meta-analyses, which are significantly inferior to randomized controlled trials and have numerous limitations. The available evidence base for the use of rivaroxaban in elderly patients with AF and VTE and critical comments on the Beers criteria methodology, indicate the recommendations of the American Geriatrics Society experts regarding direct oral anticoagulants (DOAC) should be treated thoughtfully and carefully. When choosing a DOAC in elderly patients with AF or VTE, one should primarily focus on current clinical guidelines mandatory for use in Russian Federation, and on the data of studies that studied the efficacy and safety of specific DOACs in this category of patients. Rivaroxaban is a well-studied anticoagulant in elderly patients with AF and VTE, since its efficacy and safety have been established in RCTs and specially designed multicenter prospective observational studies with a fairly high quality of evidence. Based on this, rivaroxaban is a justified treatment option for elderly and senile patients with AF or VTE.

We report a case of severe retrosternal pain in 28-year-old patient with no cardiovascular diseases in history, developed after intravenous administration of 0.5 atropine sulfate 0.1 % solution for the purpose of premedication before the planned operation for endometrioid ovarian cysts and managed with nitrates spray. Taking into account the clinical picture, transient ischemic changes in the electrocardiogram and the association with the administration of atropine, it can be assumed that the patient had a spasm of the coronary arteries caused by the administration of atropine. There are only a very small number of descriptions of similar observations in the literature, which are also discussed in the article.

Aim: to discuss current views on the clinical significance, diagnostic opportunities, and therapeutic approaches in the treatment of small intestinal bacterial overgrowth (SIBO) as an important component in the gut microbiota function assessment, to assess the awareness of physicians and the opportunities in the diagnosis and treatment of this disease in patients in the Federal districts of the Russian Federation, as well as to present the proceedings of the Expert Council held on December 16, 2023 in Moscow.Key points. SIBO is a common syndrome often associated with irritable bowel syndrome, liver cirrhosis, asthma, and congestive heart failure, being also a predictor of early death in the elderly. Today, in many regions of the Russian Federation, there are limitations for instrumental diagnosis of this disease — lack of awareness among doctors, unavailability of gas analyzers for diagnosing SIBO, lack of information about the need to diagnose SIBO in the standards of compulsory health insurance. Rifaximin is the first-line treatment due to the highest therapeutic efficacy. One of the ways to increase the efficacy of SIBO treatment is to include strain-specific probiotics in the treatment regimen. Saccharomyces boulardii CNCM I-745 is thought to be the most studied, promising probiotic. The review also presents statistical data on the issues in the diagnosis and treatment of SIBO in the regions of the Russian Federation.Conclusion. Optimization of approaches to the diagnosis and treatment of SIBO, the development of domestic gas analyzers, increasing the awareness of physicians in all regions of the Russian Federation, as well as the development and optimization of clinical recommendations appear to be necessary measures to increase the effectiveness of medical care, the duration and quality of life of the Russian population. These goals can be achieved within the framework of Federal programs under the supervision of specialized reference centers of the Ministry of Health of the Russian Federation.

The article describes an example of successful surgical treatment of an elderly patient with an arterio-ureteral fistula in the presence of an infected vascular graft after numerous arterial reconstructions on the aortoiliac segment with the multidisciplinary team support. Restoration of the magistral blood flow in the aortoiliac region using bypass surgery or graft implantation relates to a technically sophisticated surgeries, especially in patients with severe concomitant diseases and previously implanted graft infection. This is associated with the high incidence of complications, which varies from 19.2 to 45% according to different sources. In such cases, extra-anatomic reconstructive interventions that are low-traumatic may be the method of choice for relieving critical ischemia. This approach in most cases becomes the only opportunity to save a limb in such clinical situation. A pronounced cicatrical adhesion process in the abdomen and retroperitoneum caused by numerous reconstructive surgeries on the infrarenal aorta in some cases can be the cause of ureteral strictures, which requires the involvement of a urologist in the treatment of such patients. Arterio-ureteral fistula (AUF) is an uncommon but potentially lethal complication. Despite increased number of reported cases and clinical awareness, AUF is not always detected in a timely manner. The prognosis in such cases can vary depending on the time interval from onset of clinical symptoms to the start of treatment. In the vast majority of cases, the AUF is located at the site where the ureter crosses over the bifurcation of the common iliac artery. Angiography is deemed the most effective procedure to diagnose AUF, although its sensitivity is only 62%. According to most authors, implantation of an endovascular stent graft for AUF is preferred over open surgery (mortality rate is 4 and 11%, respectively). However, an individual treatment strategy is developed in each specific case

TThe annual increase in the prevalence of type 2 diabetes mellitus emphasizes the relevance of the search for new treatment options, along with necessity for regular review of proven therapeutic solutions. Today, dipeptidyl peptidase-4 inhibitors (DPP-4i, gliptins) are effective and safe hypoglycemic therapy, which is included in modern standards of treatment of type 2 diabetes. In 2022, the availability of this group of drugs for Russian patients has significantly increased. This circumstance became a prerequisite for holding a National Council of Experts with the participation of members of the Russian Association of Endocrinologists. The task of the Council was to determine the place of DPP-4i in the treatment of patients with type 2 diabetes in 2023. During the meeting of the Council, experts summarized the evidence base of DPP-4i taking into account the latest scientific data and determined the optimal clinical portraits of patients for the use of DPP-4i in accordance with updated national recommendations.

Chronic heart failure (CHF) is a complex clinical syndrome characterized by poor prognosis. According to the Russian epidemiological study EPOHA-CHF, more than half of patients with CHF have preserved left ventricular ejection fraction (LV EF). However, no class of drugs has proven effectiveness in improving the prognosis of this disease. Although current clinical guidelines do not recommend the routine use of beta-blockers in CHF patients with preserved LV EF in the absence of other indications for them, many patients with CHF with preserved LV EF take these drugs unreasonably. The review presents the data from studies on the efficacy and safety of betablockers in CHF with preserved LV EF and it withdrawal. Most studies included patient with LV EF >40%, a few of them analyzed only patients with LVEF ≥50%. Some studies of real clinical practice and meta-analysis of such studies demonstrated a positive effect of beta blockers in patients with LV EF > 40%, however randomized clinical trials and their meta-analyses revealed either a slight beneficial effect of beta-blockers. Studies involving only patients with LV EF ≥50% didn’t show the beneficial effects of beta blockers. There is only one trial accessing the withdrawal of beta blockers in patients with CHF with preserved LV EF and chronotropic insufficiency. The study showed a positive effect of deprescribing on exercise tolerance and quality of life. Due to controversial data, well-designed trials to examine the effect of beta-blockers on symptoms and prognosis in patients with CHF with LVEF ≥50% are required. Deprescribing of beta-blockers also require further assessment.

In recent decades, the prevalence of osteoarthritis (OA), one of the most disabling diseases, has increased worldwide, which imposes a significant burden on society. At the international multidisciplinary meeting, experts of various specialties (rheumatology, neurology, endocrinology, geriatrics, rehabilitation, traumatology and orthopedics) from Russia, Uzbekistan, and Kazakhstan discussed the importance of an individualized approach to the treatment of patients with OA, taking into account comorbidities, identified the most important and common clinical phenotypes of the disease, discussed known symptom- and structure-modifying effects of a combination of glucosamine and chondroitin sulfate, and new data on additional (pleiotropic) effects of these drugs that may have a positive impact on the course of comorbid diseases and conditions. The resolution of the Expert Council summarizes the results of the discussion and focuses on issues that are important for the further development of therapeutic approaches and recommendations for the management of such patients.

One of the most important trends in geroscience is the search for the biomechanisms of aging and geroprotective methods. In recent years, more and more attention has been paid to the role of age-related decline in IGF-1 levels; processes that start with a decrease in the activity of the GH/IGF-1 axis. IGF-1 levels correlate differently with many age-associated diseases: diabetes mellitus, cancer, cardiovascular disease. A decrease in the level of IGF-1 and growth hormone in the elderly can contribute to the deterioration of the course of some pathologies, and also have a protective effect in the occurrence of different nosologies. The possibility of slowing down aging with the help of IGF-1 in basic research led to research aimed at studying the possibility of using IGF-1 preparations and growth hormone in clinical practice to slow down aging. We have studied the literature on the Pubmed platform, Scopus for the past 10 years in order to find some new information regarding influence of IGF-1 on aging, about the association between IGF-1 levels and major age-related diseases. We analyzed data of publications on the role of IGF-1 in aging and the development of age-related diseases. The search was carried out using key words: IGF-1, growth hormone, aging, the review included data from more than 60 publications.

An important role in the development and evolution of hypertension in females is applied to sex hormones. Estrogen deficiency and hyperandrogenism, characteristic of periand postmenopause, are links in the pathogenesis of hypertension in this period of a woman's life and are accompanied by an increase in sympathetic nervous system activity, renin-angiotensin-aldosterone system activation, salt sensitivity, abdominal obesity and metabolic syndrome, left ventricle hypertrophy, left atrial dilatation with a high risk of atrial fibrillation, stroke and heart failure development. The paper discusses antihypertensive therapy during periand postmenopause, effectiveness and tolerability of different drug classes. Special attention is paid to the mechanism of action of selective I1-imidazoline receptor agonist moxonidine, which in women during this period both effectively reduces high blood pressure and has a beneficial metabolic effect, what is documents in studies of monotherapy, combined antihypertensive therapy with major classes and in combination with menopausal hormone therapy. The paper presents the joint expert opinion concerning above mentioned issues.

In recent decades, there has been an increase in the prevalence and medical and social burden of osteoarthritis (OA) and nonspecific back pain in all countries of the world. The First Multidisciplinary Bilateral Russia-Uzbekistan Expert Council presented innovations in the prognosing, personalized prevention and adjuvant therapy of degenerative-dystrophic diseases of the joints and spine, the evidence base for the effectiveness and safety of the use of drugs that modify the course of OA (Disease-modifying osteoarthritis drugs, DMOADs): chondroitin sulfate, glucosamine sulfate, undenatured type II collagen for adjuvant pharmaconutraceutical support – prevention and adjuvant therapy (treatment) of OA and nonspecific lumbosacral pain. The expert counsil resolution presents an optimized algorithm for the management, prevention and adjuvant therapy of OA and non-specific back pain, maintaining the function of healthy joints after intense physical activity with the inclusion of the drug Chondroguard solution for intra-articular and intramuscular administration (INN – chondroitin sulfate) and a new pharmaconutraceutical from the DMOADs group – TRIO trademark Chondroguard® (Chondroguard®TRIO).

The review article discusses the safety issue of anticoagulant therapy in elderly patients with atrial fibrillation and high risk of bleeding. An evidence base is presented demonstrating the high safety of rivaroxaban in patients over 80 years of age, with a high risk of bleeding and cardiovascular complications, the presence of comorbid pathology, geriatric syndromes and chronic kidney disease (including in combination with anemia). The problem of low adherence to treatment in elderly patients and the possibility of solving it were separately considered.

BackgroundCognitive impairment is an irreversible, aging-associated condition that robs people of their independence. The purpose of this study was to investigate possible causes of this condition and propose preventive options.MethodsWe assessed cognitive status in long-living adults aged 90+ (n = 2,559) and performed a genome wide association study using two sets of variables: Mini-Mental State Examination scores as a continuous variable (linear regression) and cognitive status as a binary variable (> 24, no cognitive impairment;

Background. Cognitive impairment (CI) is one of the important disability factors in the elderly. The role of CI in prognosis of the frailest patients with limited mobility is uncertain.The aim. To determine the influence of the initial cognitive status in the group of patronage patients aged 60 years and older on the risk of mortality within one year.Materials and methods. Study group consisted of 450 patients from patronage group with one-year period of observation (from July 2019 till July 2020). Initial physical, functional, neuropsychiatriac and social statuses were evaluated by comprehensive geriatric assessment. Cognitive impairment was screened by Mini-Mental State Examination (MMSE), with dividing patients into dementia group (MMSE ≤ 24) and no-dementia group (MMSE > 24). The mortality rate after one year was assessed.Results. Of the 450 patients included in the study, dementia was present in 44.2 %. Patients with dementia were more prone to greater severity of chronic pain, sleep disturbances, depression, malnutrition and anemia. After one year of observation 34 out of 196 patients (17.3 %) in the group of patients with dementia and 18 out of 248 patients (7.3 %; p = 0.002) in the no-dementia group died. According to multivariate analysis, independent risk factors for death in patients with dementia were anemia, hearing impairment and a history of bone fractures.Conclusion. Thus, the assessment of the cognitive status of frail patients with limited mobility is important for the purpose of identifying the most vulnerable individuals with a high risk of adverse outcomes.

Aim: present clinical guidelines, aimed at general practitioners, gastroenterologists, cardiologists, endocrinologists, comprise up-to-date methods of diagnosis and treatment of non-alcoholic fatty liver disease.Key points. Nonalcoholic fatty liver disease, the most wide-spread chronic liver disease, is characterized by accumulation of fat by more than 5 % of hepatocytes and presented by two histological forms: steatosis and nonalcoholic steatohepatitis. Clinical guidelines provide current views on pathogenesis of nonalcoholic fatty liver disease as a multisystem disease, methods of invasive and noninvasive diagnosis of steatosis and liver fibrosis, principles of nondrug treatment and pharmacotherapy of nonalcoholic fatty liver disease and associated conditions. Complications of nonalcoholic fatty liver disease include aggravation of cardiometabolic risks, development of hepatocellular cancer, progression of liver fibrosis to cirrhotic stage.Conclusion. Progression of liver disease can be avoided, cardiometabolic risks can be reduced and patients' prognosis — improved by the timely recognition of diagnosis of nonalcoholic fatty liver disease and associated comorbidities and competent multidisciplinary management of these patients.

The prevalence of older people in Russian population increases rapidly. Therefore, the concept of healthy aging is becoming crucial in Russia and all over the world, and thus disability prevention is one aspect of this issue.AimTo assess a possible association between geriatric syndromes, comorbidities, and mortality rate among frail patients who receive home medical care in Moscow.Materials and methodsThe study included 450 patients with home medical care provided by the State Budgetary Healthcare Institution “Diagnostic Center No. 3 of the Moscow Health Department” from June 2019 to April 2021. Physical health, functional, cognitive, social and emotional statuses were evaluated by comprehensive geriatric assessment (CGA). The mortality rate after 1 year was assessed.ResultsThe all-cause case mortality rate in patients during the observation period was 22.4%. There was no difference in age and comorbidities in survivors and deceased patients, but the latter group had more geriatric syndromes. The association between risks of mortality and anemia and some geriatric syndromes, such as malnutrition and hearing impairment, total dependence (Barthel index less than 60) was observed.

Russian Society of Cardiology, National Society of Preventive Cardiology

The main symptoms of osteoarthritis (OA) are pain and dysfunction of the joints. Neuropathic pain (NP) occurs in more than half of patients with OA, it is refractory in nature and is the cause for seeking medical advice more frequently, poor quality of life and disability.Objective: to evaluate the frequency of NP and its relationship with geriatric syndromes (GS) in patients with OA aged 65 years and older. Patients and methods. The subanalysis of the study EVKALIPT included 2286 patients with OA and chronic pain syndrome. All patients underwent a comprehensive geriatric assessment (CGA) and diagnostics of NP using the DN4 questionnaire.Results and discussion. The prevalence of NP in patients with OA was 22.7%. Patients with OA and NP more often experienced pain of any localization with a large number of tender points, they had a higher frequency and intensity of pain syndrome, they more often took analgesics and noted limitations in daily life. When conducting a correlation analysis, correlations of medium strength were found between the sum of scores according to DN4 questionnaire and the pain intensity assessment on a numerical rating scale at the time of examination (r=0.26; p

Cognitive dysfunction is one of the most common disorders in the elderly and senile age. There are currently 57 million people with dementia worldwide.Objective: to assess cognitive functions, to understand the prevalence of cognitive impairment (CI) and to analyze their associations with socioeconomic, demographic and anthropometric factors and geriatric syndromes in people aged ≥65 years.Patients and methods. Subjects living in 11 regions of the Russian Federation took part in the EVKALIPT epidemiological study. The inclusion criterion was age ≥65 years. Participants were divided into three age groups (65–74 years, 75–84 years, and ≥85 years) according to the protocol. All patients underwent a comprehensive geriatric assessment, comprising a specially designed questionnaire and physical examination. Cognitive functions were assessed using the mini-Cog test. The study included 3545 patients (of which 30% were males) aged 65 to 107 years.Results and discussion. According to the data obtained in our study, CI was detected in 60.8% of the subjects, and severe disorders – in 19.9% (0 or 1 point according to the mini-Cog). Patients with CI had a lower socioeconomic status. One-way regression analysis showed that the risk of CI increased by 10% with increasing age for every 1 year but did not depend on the sex of the subjects. Associated with increased CI risk also were: living alone (by 28%), living in a nursing home (by 90%), widowhood (by 2.2 times) or absence of a partner (by 2.2 times), underweight (by 2.9 times) and normal body weight (by 1.6 times), disability (by 54%), primary (by 4.8 times) and secondary (by 75%) education, bad economic conditions (by 95%). On the contrary, the presence of overweight and obesity reduced the risk of CI by 14 and 24% respectively, living in a family – by 24%, having a spouse – by 55%, divorce – by 29%, having a job – by 73%, higher education and a scientific degree – by 55 and 59%, medium and good economic conditions – by 38 and 52%, respectively. In patients with CI, the incidence of all geriatric syndromes was higher.Conclusion. The frequency of CI among elderly patients was higher compared with data from other studies. The EVKALIPT study was the first to obtain national data on the prevalence and characteristics of CI in persons aged ≥65 years in the general population.

High blood pressure is a risk factor for cardiovascular morbidity and mortality, as well as cognitive decline and loss of autonomy in the elderly and old age. Randomized clinical trials (RCTs) in populations of older patients living at home with low comorbidity and preserved autonomy indicate the benefit of lowering elevated blood pressure in patients over 80 years of age. Older patients with senile asthenia, loss of autonomy and other geriatric problems were excluded from RCTs, and observational studies in these groups of patients indicate an increase in morbidity and mortality with lower blood pressure and antihypertensive therapy. Obviously, in very elderly patients, a universal strategy for the treatment of arterial hypertension cannot be applied due to the significant heterogeneity of their functional status. The geriatric approach to the management of arterial hypertension in older patients involves an assessment of the functional status, the presence of senile asthenia, and the degree of autonomy for the choice of antihypertensive therapy tactics.

Over 10 million operations are performed each year in Russia. A successful surgical treatment demands assessment and mitigation of perioperative risks, one of which is anemia. Patients with low hemoglobin are at greater risk of developing complications and adverse outcomes. These patients more often stay longer at hospitals, have more in-hospital events and readmissions.Perioperative anemia may be present before surgery, low hemoglobin levels can result from surgery, and can persist after hospital discharge. Preoperative anemia is associated with inferior surgical outcomes and is also an independent risk factor for perioperative complications (acute kidney injury, infectious, thromboembolic, cardiovascular events) and death. Postoperative anemia impairs recovery and increases the risk of reoperations and readmissions.Absolute and functional iron deficiency is the most common cause of anemia in the perioperative period. The prescription of iron supplements is indicated in the presence of iron deficiency. If the operation is scheduled to be performed in 6 weeks and longer, the prescription of oral iron forms is recommended. If less than 6 weeks remain before surgery, parenteral iron therapy is prescribed. If hemoglobin levels increase insignificantly during such therapy, high-dose iron supplements are indicated. When it comes to emergency surgery and the anemia is not severe, it is recommended to intravenously administer high-dose iron supplements immediately before surgery. In case of severe anemia, blood transfusion is indicated. According to the patient’s blood management concept, blood transfusion should be minimized, including due to the use of high-dose iron supplements, one of which is ferric carboxymaltose.The choice of treatment for anemia in the postoperative period depends on its severity, the patient’s comorbidities, the type of surgery and the presence of surgical events. In most cases, early intravenous iron therapy is recommended, giving priority to single administration of high-dose iron supplements. Blood transfusion is indicated to patients who have severe anemia, are actively bleeding, and to patients with a severe anemia after the bleeding has been stopped. Iron therapy continues at the outpatient stage of treatment for a long time until the hemoglobin and ferritin levels are normalized, reflecting the replenishment of iron stores in the depot organs.

Today, abdominal aortic aneurysm surgery is a fairly well-studied area of medicine. Nevertheless, some questions remain rather debatable. No clear criteria for giant aneurysms have been developed so far. The available foreign and domestic literature reports about 40 cases of surgical treatment of giant abdominal aortic aneurysms, 16 of which are cases of aneurysm rupture. Open surgery remains the method of choice in the treatment of giant aneurysms due to the pronounced technical difficulties of endovascular intervention. The authors present a case of successful surgical treatment of a giant aneurysm rupture in an elderly patient. The peculiarity of this patient's condition is the occurrence of aneurysm rupture after hospital admission. The patient refused surgical treatment for two years after aneurysm detection. On examination after admission, multispiral computed tomography revealed an aneurysm size of 101 mm. On the eve of surgery, pain syndrome in the left abdomen and tachycardia appeared. Aneurysm rupture was suspected and the patient was urgently admitted to the operating room. The surgery was performed under the conditions of machine reinfusion of autoblood. The patient underwent abdominal aortic aneurysm resection with linear prosthesis and retroperitoneal hematoma removal. The postoperative period had no peculiarities. On the 10th day after the operation the patient was discharged in satisfactory condition to the outpatient treatment. This clinical case demonstrates the possibility of successful surgical treatment of giant aneurysm rupture in elderly patients.

Aim: To assess an association between orthostatic hypotension and arterial stiffness, measured by the cardio-ankle vascular index (CAVI), in a group of patients≥60 years of age with arterial hypertension and frailty.Materials and methods: The study included 160 patients aged 60 to 101 years with confirmed arterial hypertension without severe concomitant physical disorders. Compliance to the previously prescribed medications was assessed. A short questionnaire, "Age is not a hindrance," was used to identify patients with frailty. According to the current diagnostic algorithm for frailty, the patients were categorized into three groups: group 1, frail, group 2, pre-frail, group 3, healthy. Arterial stiffness was assessed by volumetric sphygmometry (VaSera-VS-1500, Fukuda Denshi, Japan) with the measurement of CAVI. The orthostatic test was considered positive if blood pressure falls by≥20/10 mm Hg after changing from supine to standing position.Results: The mean age of the study patients was 77.2±8.1 years (n=160), being 72.4±6.9 years in the healthy patients (n=50), 76.6±8.1 years in the pre-frail (n=50) and 81.7±6.6 years in the frail patients (n=60). Orthostatic hypotension was identified in total of 53 (33%) patients, with marginally significant difference between the pre-frail and healthy groups (44 and 20% of the patients, respectively, p=0.053). The CAVI values were higher in frail patients, compared to healthy ones (p=0.0005). Orthostatic hypotension was associated with a higher CAVI, irrespective of the patients’ age and frailty (р=0.0067). The association between orthostatic hypotension and CAVI in frail patients was found only with unifactor analysis, but became non-significant with the additional analysis.Conclusion: Orthostatic hypotension can be found in 33% of the elderly patients with arterial hypertension. Arterial stiffness increases with increasing frailty, as well as with concomitant orthostatic hypotension in the group of the patients≥60 years of age. The progression of arterial stiffness in the elderly group is heterogeneous and depends on the presence of frailty.

Osteoarthritis (OA) is the most common pathology of the musculoskeletal system and is a serious medical and social problem. OA is of particular importance in elderly and senile people due to the high frequency of comorbid pathology. Pain relief is a priority in the formation of individual therapeutic programs for patients with OA, starting from their first request for medical assistance. At the same time, due to the ambiguity of existing clinical recommendations, most experts note a number of difficulties in prescribing treatment for patients with OA.The article presents a consensus position of experts regarding a complex approach to the choice of therapy in patients with OA at the initial visit to the doctor. The article discusses: current clinical guidelines for the management of patients with OA; most common problems in the management of patients with OA in real clinical practice; goals of treatment strategies for OA taking into account the risk factors for its progression; an algorithm of pain relief during initial treatment in patients with OA; prevention of OA exacerbations with the use of basic structure-modifying drugs; recommendations for the choice of non-steroidal anti-inflammatory drugs.According to experts, a rational approach to the treatment of OA is based on the combined use of non-drug and pharmacological methods with constant monitoring of therapy regimens and side effects. These recommendations can be considered disease-modifying strategies that in many cases allow improving functional status and achieving long-term remission in patients with OA.

Clinical guidelines have long been one of the working tools of the modern doctor, helping him quickly navigate the most effective proven methods of treatment and prevention of various diseases, and also to adapt these methods to the specific tasks of their patients and to achieve maximum personalization of treatment. Clinical practice guidelines are drawn up by professional non-profit associations and are approved by the Scientific Council of the Ministry of Health of the Russian Federation, while often one recommendation is prepared by two or even three associations. The peculiarity of the recommendations offered to your attention is that not only endocrinologists, but also therapists, cardiologists, gynecologists, gastroenterologists, and experts of many other specialties are involved in the prevention and treatment of obesity. The Multidisciplinary Working Group presents this a project in a multidisciplinary journal to bring together the efforts of several professional associations that associated with the need to pay attention not only to obesity itself but also to comorbid conditions. We are looking forward to constructive criticism and a comprehensive discussion of the problem on the pages of our journal.

The administration of oral anticoagulants in elderly patients with geriatric syndromes such as senile asthenia syndrome, falls and high risk of falls, dementia, polymorbidity, polypharmacy are discussed in the article. The evidence base for the anticoagulants taking in patients with atrial fibrillation aged ≥75, ≥80, ≥85 and ≥90 years, in patients with atrial fibrillation and various geriatric syndromes, as well as in elderly patients with venous thromboembolic complications and frailty syndrome is presented. Most studies indicate significant advantages of direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) over the vitamin K antagonist warfarin in elderly patients with geriatric syndromes. An updated version of the FORTA consensus document, which aims to optimize the prescription of medicines for the elderly, is also presented. Apixaban has a FORTA-A safety class and is the safest oral anticoagulant in elderly patients.

Cardiovascular diseases are the main death causes in the modern world. Heart failure (HF) is the terminal stage of most cardiovascular diseases. The prevalence of HF is increasing in patients of older age groups. At the same time, the number of geriatric syndromes increases with age, one of which is malnutrition. Recent studies demonstrate the mutually aggravating effect of heart failure and malnutrition, and that the correction of malnutrition can improve the heart failure course. The introduction of screening and timely correction of malnutrition will reduce the hospitalization and mortality rates in geriatric patients with HF.

For the treatment of dementia and Alzheimer’s disease, acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) and/or the non-competitive inhibitor of N-methyl-D-aspartate receptors (NMDA receptors) memantine are currently used. The administration of these drugs can help temporarily improve or stabilize memory impairments and other cognitive functions, regress behavioral disorders, reduce the patient’s dependence on others, but at the same time can lead to the development of adverse drug reactions. The aim of this study was to analyze the information on the safety of acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) and the non-competitive inhibitor of NMDA receptors used to treat dementia. It was shown that stimulation of cholinergic receptors can lead to adverse drug reactions as contraction and narrowing of the pupil (miosis), an increase in lens curvature, accommodation spasm (visual impairment and an increased risk of falls), a decrease in heart rate (bradycardia) and inhibition of conduction of impulses through the conducting system heart, increased tone of the bronchi, gastrointestinal tract, gall and bladder, decreased tone of the sphincters of the digestive tract and bladder, increased secretion of exocrine and glands of the stomach, agitation, confusion. Blockade of NMDA receptors due to impairment of glutamate metabolism in the central nervous system may be the cause of neurotoxicity of NMDA receptor antagonists, and also causes dizziness, feeling of tiredness, hallucinations, drowsiness, and confusion. In case of development of adverse reactions, if possible, it is necessary to stop using the drug or reduce its dose, in case of an overdose or other need, prescribe symptomatic therapy. Information on the safety of cholinesterase inhibitors and NMDA receptor antagonists presented in the article is of practical importance for healthcare professionals, as it allows them to assess the possible risks associated with the use of drugs of these groups more accurately. In addition, the information can be used to optimize and individualize the pharmacotherapy regimens for patients with dementia, including the development of domestic protocols for the deprescribing of drugs (evidence-based practice of withdrawal, replacement or gradual dose reduction) in the elderly.

Aim. To study the relationship between telomerase activity and parameters of carbohydrate metabolism and vascular wall depending on the type 2 diabetes (T2D).Material and methods. The study included 50 patients with T2D and 139 healthy volunteers. All subjects were assessed for carbohydrate metabolism, chronic inflammation (C-reactive protein (CRP), fibrinogen), endothelial dysfunction, carotid intima-media thickness and number of atherosclerotic plaques by duplex scanning, carotid-femoral pulse wave velocity, lymphocyte telomere length and telomerase activity.Results. In T2D patients, telomerase activity was lower (p=0,039), telomeres were shorter (p=0,031) and CRP level was higher (p=0,031) than in patients without T2D. All patients were divided by telomerase activity. T2D patients with low telomerase activity had higher values of CRP (р=0,016), pulse wave velocity (р=0,010), carotid intima-media thickness (р

The paper discusses the issues of managing uncontrolled hypertension. It is noted that in the International Classification of Diseases, 10th revision (ICD-10), there is no diagnosis “hypertensive crisis”, which complicates the epidemiological estimates. In the new Russian Society of Cardiology guidelines, instead of using the term “uncomplicated hypertensive crisis”, the term “sudden pronounced individually relevant blood pressure (BP) increase” was proposed to describe pronounced BP increase without target organ damage. Since the term “uncomplicated hypertensive crisis” is not recommended for use, but this condition is often diagnosed in practice, it is advisable to replace this term with “sharp BP increase not accompanied by target organ damage” or “sudden pronounced individually relevant BP increase”. At the same time, there is no evidence that in patients with uncomplicated hypertensive crisis, a more rapid BP decrease is more effective over the standard antihypertensive therapy in relation to the risk of complications. The drug Physiotens® lowers BP smoothly and without sudden falls, while having favorable pharmacokinetics. The issues of revising the current approaches to antihypertensive therapy in patients with frequent BP increases, as well as the use of original drugs and generics are considered.

Anticoagulant and antiplatelet agents are used to prevent stroke and thromboembolic events. There is insufficient data on the effect of these drugs on bone tissue. In addition, the available data are ambiguous, which increases suspicion when used in individuals at high risk of osteoporosis. The article provides data on the effect of anticoagulant and antiplatelet agents on bone metabolism, bone mineral density and the fracture risk. Literature data indicate a negative effect of heparin on bone tissue, which is increase the risk of fractures. Low molecular weight heparins has lower effect on bone tissue than heparin. It is known that vitamin K antagonists significantly affect bone metabolism and markers of bone formation, however, data on the effect on bone mineral density and the risk of fractures are contradictory. Direct oral anticoagulants are relatively safe in relation to bone tissue. Data on the effects of antiplatelet drugs on bone are ambiguous.

The review addresses the issue of the gastrointestinal bleeding (GIB) development in patients receiving oral anticoagulants, and the proton pump inhibitors (PPIs) efficiency in reducing of such complications. Epidemiological data on the prevalence of GIB in the presence of nonwarfarin oral anticoagulants (NOACs) and warfarin intake are presented. The factors that increase the risk of bleeding associated with the use of anticoagulants are discussed, including the potential drug-drug interactions and patients’ dietary habits. A description of the scales that assess the bleeding risks during anticoagulant therapy is given. In the second part of the article the principles of prevention and minimization of the GIB risks in the presence of oral anticoagulants treatment are presented. In the context of evidence-based medicine, the PPIs’ role in reducing the risk of GIB is fully discussed. The results of recent large-scale randomized clinical trials and meta-analyses are described in detail, suggesting the benefits of PPIs in the decreasing the risk of the upper gastrointestinal tract bleeding when NOACs and warfarin are prescribed, especially with concomitant therapy with acetylsalicylic acid. So, PPIs can be considered as one of the effective drug prevention “tools” of these complications.

Chronic pain among the elderly aged 60 years and above is one of the «big» geriatric syndromes, and has great prognostic significance in relation to cognitive, functional and physical status.The loss of muscle strength, mass (sarcopenia) is one of the important components of chronic pain syndromes in elderly patients. Pathological findings were demonstrated by own observation of 116 patients in the geriatric unit aged 75,667.98 years (110 women, 94.8%). Most patients had a combination of several geriatric syndromes, an average of which accounted for 6.6. Among them, there were falls - 72 (62.1%), chronic pain - 85 (73.3%), senile asthenia - 51 (43.9%), etc. In most cases, chronic pain was due to osteoarthritis. According to the dynamometry data, a decrease in muscle strength was found in 45.9% of cases, without chronic pain syndrome in 9.7% of cases among patients with chronic pain syndrome. Thus, prevalence rates of decreased muscle strength were higher in patients with chronic pain, than in patients without pain. In addition, a significantly lower walking speed was found, which indicates a poor prognosis in patients of older age groups.Sarcopenia and chronic pain treatment programs for elderly patients contain a number of evidence points: therapeutic exercises, adequate intake of calories and protein, vitamin D3, reduction of the number of drugs, chondroitin sulfate (Chondrogard), glucosamine sulfate (Sustagard Artro). This program, being multicomponent, should be long and regular.

New oral anticoagulants are effective for the prevention of thromboembolic complications in patients with atrial fibrillation, or after orthopedic surgery. The use of these drugs may be associated with the risk of bleeding from the gastrointestinal tract — a dangerous complication, which can potentially lead to death. The aim of this research was systematization and analysis of information on the interactions of new oral anticoagulants with other drugs and food products, and the identification of potentially dangerous combinations that increase the risk of gastrointestinal bleeding. To assess the risk of a heavy bleeding in patients with atrial fibrillation taking oral anticoagulants to prevent thromboembolic complications, HAS-BLED scale is used. In some cases activated partial thromboplastin time, ecarin clotting time, anti-FXa, etc. can be used to assess the effectiveness of the oral anticoagulants. Potential combinations that increase the risk of bleeding include the simultaneous administration of new oral anticoagulants with antiplatelet agents, anticoagulants, including vitamin K antagonists, unfractionated heparin, low molecular weight heparins, nonsteroidal anti-inflammatory drugs, antidepressants along with other drugs and foods (curcumin, grapefruit juice, peppermint, eucalyptus, etc.). The administration of proton pump inhibitors, as well as the elimination of potentially dangerous combinations of drugs and food with new oral anticoagulants, can help prevent gastrointestinal bleeding.

Malnutrition is a patient’s condition with high relevance and importance for elderly patients (most often seen in very old patients >80 years old), since it is associated with a high risk of progressive worsening of their state, prolongation of hospitalization and death. Exposure to some drugs may increase the risk of malnutrition, especially in elderly patients. The purpose of this work is to provide an overview of the causes of malnutrition, focusing on the pharmacological risk factors, as well as to highlight the existing methods of correction of this condition. The authors show that one of the key reasons for developing drug-induced malnutrition is the patients exposure to drugs, that reduce appetite, cause nausea and vomiting, change taste and olfactory sensations, and have anticholinergic effects. Use of pharmacological (additional prescription of drugs for symptomatic therapy, changing the dose, deprescribing drugs, etc.), and nonpharmacological (diet therapy, adding artificial and natural identical flavors, etc.) treatment methods may help to improve state of patients with already developed pathological condition.

The review focuses on the use of oral anticoagulants in fragile elderly patients. The issues of prevalence and diagnosis of senile asthenia syndrome or “fragility”, as well as its effects on the risks of thrombosis, bleeding and death, are discussed. The evidence base, which is quite limited, for the participation of fragile elderly patients in randomized controlled trials and real clinical practice trials with direct oral anticoagulants is presented. Nevertheless, one of the studies of real clinical practice showed that only therapy with rivaroxaban (out of three direct oral anticoagulants) compared with warfarin reduced the risk of stroke/systemic embolism and ischemic stroke alone in fragile elderly patients with atrial fibrillation after 2 years of observation.

Abstract. The demographic aging of the population of the earth observed in recent years is associated, inter alia, with the advent of new effective and safe medicines. However, the availability of highly effective drugs on the market also has a reverse side — the appearance of adverse drug reactions (ADRs), in particular as a result of drug-drug interactions. The use of non-pharmacological methods of treatment and prevention of diseases seems particularly relevant for patients of the older age group, as it allows not only to reduce the drug burden, to reduce the risk of ADRs but also to improve the patient’s state in case of diseases that have no effective pharmacotherapy and pharmacological prophylaxis. The aim of the study was to systematize and analyze data on non-pharmacological treatment methods in order to increase the safety of pharmacotherapy and prevent polypragmasia in elderly patients by informing health care providers about non-drug methods of correcting significant geriatric problems. The approaches to the correction of some major geriatric problems (delirium, sarcopenia, pain syndrome), including cognitive training, physical activity, diet, frequent reorientation of patients, placement of patients in specially equipped rooms («delirium room») were presented. The use of non-pharmacological approaches can significantly improve the safety of drug therapy, reduce the risks of ADRs, improve the patient’s prognosis and quality of life, and also effectively prevent polypharmacy.

Abstract. Elderly patients are at higher risk of developing infectious diseases that might have more severe progression than those of younger age groups, accompanied by an increased risk of death. These medical conditions in elderly may also present difficulties for diagnosis due to a «blurred» clinical picture. By WHO recommendations the vaccination against influenza is one of the most effective ways to prevent this type of infection in elderly patients. However the use of vaccines may be associated with a risk of adverse drug reactions. In most cases, they have subclinical manifestations and/or non-severe clinical manifestations (adverse reactions), but in a relatively small percentage of cases, the use of vaccines may be associated with a risk of developing serious post-vaccination complications (anaphylaxis, Guillain-Barre syndrome etc.). This article represents data on the safety of influenza vaccines in patients over 60 years old, with due regard to immunosenescence. According to the authors opinion, this will improve the safety of vaccination against influenza patients 60 years and older. At the end of the article, the authors conclude that despite the potential risks, the by the benefits of the use of influenza vaccines continue to overweight potential risks and vaccination of elderly people is effective and safe way to prevent influenza. To improve the effectiveness of vaccination of patients 60 years and older the use of high dose vaccines and adjuvants can be recommended.

Aim. To study the relationship of vascular stiffness (cardio-ankle vascular index (CAVI)) with frailty and other geriatric syndromes in hypertensive elderly patients.Material and methods. The study included 160 patients aged 60 to 101 years with verified stage I-III hypertension. The previous therapy was assessed. A comprehensive geriatric assessment was performed with functional and neuropsychological tests to identify geriatric syndromes. Vascular stiffness was assessed by VaSera-VS-1500 vascular screening system (FUKUDA DENSHI, Japan) with determination of the CAVI.Results. The mean age of the patients was 77,2±8,1 years (n=160): in the group of patients without frailty — 72,4±6,9 years (n=50), with prefrailty — 76,6±8,1 years (n=50), with frailty — 81,7±6,6 (n=60). Patients with frailty had a higher CAVI than those without frailty and with prefrailty (10,3±1,6 vs 9,3±1,0 and 9,6±1,8, respectively; p=0,002).In patients with frailty, a negative correlation was found between the vascular stiffness and body mass index (BMI) (Rs=-0,392 (p=0,002)), and a positive correlation between the CAVI and orthostatic response (Rs=0,382 (p=0,003). In patients with prefrailty, negative relationships were found with the dynamometric parameters (Rs=-0,329 (p=0,019)), BMI (Rs=-0,343 (p=0,015) and physical activity (Rs=-0,285 (p=0,047)).In patients without frailty, the vascular stiffness was associated with an increased total cholesterol level (Rs=0,379 (p=0,009)), a low physical activity (Rs=-0,355 (p=0,015)), as well as negative correlations were found with the clock-drawing test and falls (Rs=-0,458 (p=0,011) and Rs=-0,306 (p=0,031), respectively).Conclusion. Vascular stiffness in elderly patients with frailty is associated with a decrease in body mass index and orthostatic hypotension. At the stage of prefrailty, the relationship between the vascular stiffness and muscle strength decrease (according to dynamometry) was revealed.Thus, the vascular stiffness is associated with frailty markers itself.

В данном документе обсуждаются особенности АТТ у лиц пожилого и старческого возраста в различных клинических ситуациях.

Over the past century, an increase in life expectancy has been observed in Russia and in the world. According to the United Nations, by 2100, the number of centenarians worldwide will reach 25 million. Despite the annual increase in the number of super-centenarians, this age group remains poorly understood.Aim. To estimate the prevalence of cardiovascular diseases (CVD) and the main risk factors among super-centenarians in Moscow.Material and methods. According to the register of long-livers in Moscow, 82 people aged 95 to 105 were included. Participants were examined at home.The history of life and the presence of chronic diseases was collected by participant words. To assess the state of cardiovascular system, an ultrasound of the heart and main arteries was performed.Results. Conventional CVD risk factors were the exception rather than the rule among study participants (smoking — 8 patients (9,8%), alcohol abuse — 4 (4,9%), obesity — 6 (7,3%)). Dyslipidemia was relatively widespread (n=37; 45,1%), however, there were no pronounced abnormalities in the lipid profile: the maximum increase in low-density lipoproteins was 5,6 mmol/L. The most common CVDs among the participants were hypertension (n=64; 78%), coronary artery disease (n=42; 51,2%), and heart failure (n=26; 31,7%); other diseases were much less common. The most common echocardiographic changes were left atrial dilatation (n=38; 74,5%), increased left ventricular mass, thickening of left ventricular posterior wall (n=24; 48%) and interventricular septum (n=51; 100%). Diastolic and systolic heart failure were not widespread among long-livers: 16 (32%) and 2 (3,9%), respectively. Despite a rather large number of atherosclerotic plaques in the common carotid and femoral arteries, the number of hemodynamically significant plaques was low (n=3; 4,6%). An intima-media thickening up to 1,0-1,1 mm was found.Conclusion. Long-livers in Moscow are characterized by a low prevalence of traditional CVD risk factors (with the exception of hypertension) and a fairly high prevalence of atherosclerotic CVDs, which are characterized by a subclinical course.

The purpose of the first multidisciplinary Consensus: to comprehensively analyze the pathophysiological, clinical, and pharmacotherapeutic aspects of the syndrome of increased epithelial permeability (SPEP) as one of the basic mechanisms of the development of human pathology.The Consensus presents the structure of the three main levels of cytoprotection: preepithelial, epithelial and subepithelial, and the structure of intercellular tight contacts in epithelial tissues and endothelium is considered in detail. The clinical sections of the Consensus are devoted to the role of SPEP in diseases of the digestive system, cardio-cardio-vascular and other visceral systems. A separate section summarizes the materials illustrating the significant role of SPEP in mental disorders and diseases of the nervous system.A separate chapter of the Consensus is devoted to cytoprotective therapy in SPEP. Cytoprotective effects of such proton pump inhibitor as rabeprazole, bismuth preparations and probiotics have been shown. Special attention is paid to the clinical and pharmacological specialties of the cytoprotector of rebamipide. Clinical the effectiveness of re-bamipide shown as in functional, so in organic lesions of the digestive system. Its anti-cancer preventive effects are of practical importance.

Aim. To study the prevalence of geriatric syndromes and assess their relationship with senile asthenia in persons aged ³65 years living in Russian regions with different demographic, climatic and socio-economic characteristics.Material and methods. We examined 664 patients aged 65-107 years (mean age, 79±9 years; men, 25%) living in Moscow (n=365) and Voronezh (n=299). All patients underwent a comprehensive geriatric examination, which consisted of two stages: a survey with original questionnaire and an objective examination.Results. The prevalence of senile asthenia was 66,4%, including 47,4% in people aged 65-74, 71,1% — 75-84 years, and 82,8% — ³85 years (p for trend

The review includes data over the past 20 years on the mechanisms of the influence of hypertension and related interdependent conditions, such as insulin resistance, chronic inflammation and oxidative stress on the vascular ageing. The review also discusses modern concepts of the interaction of biological and vascular aging, as well as possible ways of their reversal. The central indicators of biological aging in this review are telomere length and telomerase activity. The article discusses antihypertensive therapy as a possible way to slow down both vascular and biological aging, and describes the results of modern studies on the effect of various antihypertensives, including angiotensin-converting enzyme inhibitors, sartans and others, on the telomeres.

The pandemic of the novel coronavirus infection (COVID-19), caused by SARS‑CoV‑2, has become a challenge to healthcare systems in all countries of the world. Patients with comorbidity are the most vulnerable group with the high risk of adverse outcomes. The problem of managing these patients in context of a pandemic requires a comprehensive approach aimed both at the optimal management in self-isolated patients not visiting medical facilities, and management of comorbidities in patients with COVID-19. The presented consensus covers these two aspects of managing patients with cardiovascular disease, diabetes, chronic obstructive pulmonary disease, gastrointestinal disease, and also pay attention to the multiple organ complications of COVID-19.

Changes in the intestinal permeability in various pathologies are widely discussed in the scientific community. There is still no consensus on whether high intestinal permeability can lead to chronic noncommunicable diseases, but there is much evidence that increased permeability can aggravate some of them. The article discusses a modern vision of the intestinal permeability including its potential contribution to the development of cardiovascular pathologies, which are the number one mortality cause both in Russia and around the world.

A novel coronavirus infection SARS-CoV-2 (COVID19) is especially dangerous for elderly and senile patients. Preventive measures for elderly people should cover three areas: 1) direct prevention of the viral infection, 2) preservation of the functional status and prevention of geriatric syndromes, including the use of social support measures, 3) control of comorbidities. The clinical pattern of COVID-19 in older patients may be atypical, while the mildness of symptoms (no fever, cough, shortness of breath) may not correspond to the severity of the prognosis. Delirium may be the first manifestation of COVID-19, which requires special care in its screening. Management of elderly and senile patients with COVID19 should include measures for delirium prevention, the detection and improvement of nutrition. The risk of malnutrition with sarcopenia increases with hospitalization of a patient, especially when using artificial ventilation, is associated with an unfavorable prognosis during hospitalization, accelerates the progression of senile asthenia and reduces the quality of life. Geriatric assessment is the cornerstone of determining the management of an elderly patient.

Arterial hypertension in adults. Clinical guidelines 2020

Expert Council opinion describes emergency care in a sudden individually significant blood pressure (BP) increase without clinically overt target organ damage. In the new guidelines of the Russian Society of Cardiology, the term “hypertensive urgency” was abolished, and the management of a sudden BP increase was changed. At the same time, a sudden individually significant BP increase may be accompanied by symptoms that reduce patients’ quality of life and ability to work. According to experts, individually significant BP increase accompanied by symptoms requires outpatient treatment using oral rapid-onset drugs with an optimal duration of action, in particular captopril. It has a much evidence-based data on the BP increase use and sublingual administration, and also has a favorable safety profile, which allows prescribing to patients with comorbid diseases. The rationale for the use of angiotensin-converting enzyme inhibitor Capoten (captopril) as a drug for self-management of a sudden individually significant BP increase accompanied by symptoms in hypertension patients is describes.