Method for predicting the risk of developing adverse cardiovascular events in patients with confirmed acute coronary syndrome

Abstract

FIELD: cardiology; angiology.SUBSTANCE: used to predict the risk of developing adverse cardiovascular events in patients in the first year after the onset of acute coronary syndrome. Computed tomography angiography (CTA) is performed to assess the quantitative and qualitative characteristics of atherosclerotic plaques, including their extent, density, the presence of spotty calcifications, and the degree of arterial stenosis. Each identified feature is assigned a point coefficient. If the total score is more than 3, a high risk of complications is predicted.EFFECT: method improves the accuracy of early detection of patients at risk, including those with non-obstructive lesions, which will enable timely selection of personalized pathogenetic therapy to restore coronary blood flow and myocardial metabolism, as well as prevent the progression of atherosclerosis and thrombus formation in vital vascular beds, reducing the risk of premature mortality through a comprehensive analysis of plaque morphology and obstruction parameters based on CTA data.1 cl, 1 tbl, 5 ex

Description

[0001] The invention relates to medicine, namely to cardiology, angiology, cardiac surgery, rehabilitation, and can be used to predict the risk of developing adverse cardiovascular events (CVE) in patients with confirmed acute coronary syndrome (ACS).

[0002] A method for predicting the development of cardiovascular complications of acute coronary syndrome is known, which includes conducting an instrumental study followed by scoring according to the GRACE scale.

[0003] (Patent of the Russian Federation No. 2567031, IPC G01N 33 / 48, published October 27, 2015, Bulletin No. 30)

[0004] The disadvantages of this method are that it allows assessing the risk of complications only in patients with ACS with ST-segment elevation and only in the acute period of ACS, whereas in our development - all patients with ACS and to evaluate the 1-year prognosis. In addition, the composite endpoint (CEP), dividing patients into 2 subgroups - with and without events, includes 9 types of complications, including 5 related to rhythm and conduction disturbances, most of which are reversible in the acute period of the disease in the majority of patients and do not significantly affect the prognosis of serious outcomes - ACS recurrence, death, the development of ischemic stroke. These include paroxysms of supraventricular tachycardia, atrial fibrillation, episodes of ventricular extrasystole, which are often short-lived; episodes of A-V block II-III degree.and C-A blockades, which in case of inferior myocardial infarction, as a rule, are transient in nature and in this case, like the aforementioned tachystolic arrhythmias, cannot actually be considered as outcomes.

[0005] Predicting the course and outcome of acute coronary syndrome is a common practice, taking into account clinical, electrocardiographic, and biochemical parameters. This allows for the creation of prognostic tables and systems for assessing the risk of adverse outcomes in patients with ACS. For example, risk assessment using the TIMI (Thrombolysis in Myocardial Infarction) system involves using data such as risk factors, the presence of stenoses, angina attacks in the 24 hours prior to hospitalization, aspirin use in the previous week, elevated myocardial damage markers, and the presence of ST segment shifts on the electrocardiogram (ECG), followed by scoring.In this case, the group of patients with a high immediate risk of death or development of acute myocardial infarction (AMI) includes patients with a score of 4 or higher; accordingly, if the score is 3 or less, then these patients belong to the group with a low risk of death or development of AMI.

[0006] (Recommendations of the All-Russian Society of Cardiologists for the treatment of acute coronary syndrome without persistent ST segment elevation on the ECG / Gratsiansky N.A., Oganov R.G., Agapov A.A. et al. / / Supplement to the journal "Cardiology", Vol. 44, No. 4, 2004. - 28 p.)

[0007] The disadvantages of this method are that it allows us to assess the risk of adverse outcomes only in patients with ACS without ST segment elevation and only in the acute period of ACS, whereas in our development - in all patients with ACS and a one-year prognosis after the occurrence of ACS, i.e. for a longer period.

[0008] The objective of the invention is to create an effective method for predicting the risk of developing adverse cardiovascular events in patients with confirmed acute coronary syndrome, especially after optimal treatment in the acute phase of the disease, including percutaneous coronary intervention (PCI), including in patients without remaining obstructive stenosis, but with certain characteristics of atherosclerotic plaques (ASP), allowing for special attention to be paid to the management of patients with an increased risk of adverse cardiac events, aimed at reducing the risk of possible complications in the early and subsequent stages of the disease and preventing recurrent acute coronary syndrome, ischemic stroke and premature mortality of the population.

[0009] The technical result of the invention is to increase the accuracy of forecasting.

[0010] This is achieved by the fact that in the claimed method for predicting the risk of developing adverse cardiovascular events in patients with confirmed acute coronary syndrome by performing computed tomography angiography (CTA) on the patient to determine the quantitative and qualitative characteristics of atherosclerotic plaques, signs of coronary artery (CA) obstruction and plaque distribution in them with assignment of points to each sign, where "Number of arteries with ASP> 1.5" corresponds to 1.00 point; "Maximum length of ASP> 14.5 mm" corresponds to 1.16 points; "Total length of ASP> 22.5 mm" corresponds to 1.17 points; "Maximum stenosis of ASP> 77.5%" corresponds to 1.23 points; "Number of ASP with obstructive stenosis> 3.5" corresponds to 1.10 points; "Minimum density of atherosclerotic plaques <29.1 HU" corresponds to 1.33 points; "Number of atherosclerotic plaques with spotty calcifications >1.5" corresponds to 1.23 points; "Number of atherosclerotic plaques with a low-density area (lower part of the plaque).) <30 HU>0.5" corresponds to 1.00 point; and based on the results of the sum of points more than 3, the risk of developing adverse cardiovascular events in patients in the first year after the onset of acute coronary syndrome is predicted.

[0011] Implementation of the method.

[0012] The patient undergoes computed tomography angiography to determine the quantitative and qualitative characteristics of atherosclerotic plaques, signs of coronary artery obstruction, and plaque distribution within them. Table 1 shows the scoring system for the "Risk Score," listing the CTA characteristics, their cutoff ("threshold") values, and the points awarded if the value of the corresponding CTA characteristic determined in the patient falls outside the "threshold."

[0013]

[0014] According to the table, CTA characteristics whose values ​​exceed the threshold are determined. The scores are then summed, and if the total score is greater than 3 (i.e., the presence of 3 or more of the CTA characteristics listed in the table), a high risk of adverse cardiovascular events is identified in the patient within the first year after the onset of acute coronary syndrome.

[0015] The claimed method was developed based on the results of a long-term prospective study of the predictive value of multiple quantitative and qualitative characteristics of atherosclerotic plaques, signs of coronary artery obstruction, and the distribution of atherosclerotic plaques within them, based on computed tomography angiography data. The total duration of the study was 128 months, with a study inclusion period of 116 months. Based on the results of CTA performed in the subacute period of ACS (the index event) after percutaneous coronary intervention in 249 patients finally included in the study, 30 CTA characteristics were identified. To determine the prognostic significance of these characteristics in the development of adverse cardiovascular events, patients were followed up until the development of a composite primary endpoint (CPE), death from non-cardiovascular causes, or the end of the study if no CPE events occurred.The following adverse cardiovascular events were included in the PCT: myocardial infarction, unstable angina, cardiovascular death, unscheduled (delayed) myocardial revascularization, and ischemic stroke. The follow-up period was 39.1 months. During this period, PCT was achieved in 71 patients (28.5%). According to univariate Cox analysis, 14 of 30 CTA characteristics were significantly associated with achieving PCT. According to the results of multivariate Cox analysis, 11 CTA characteristics were significant predictors of PCT. That is, the majority of significant univariate CTA predictors were independent of known clinical risk factors.

[0016] The next step was to conduct a ROC (Receiver Operating Characteristic) analysis of univariate CTA predictors significantly associated with the occurrence of PCT events, primarily to determine cutoff values. Since ROC analysis is not performed for data containing censoring, it was necessary to calculate the patient observation period during which no censoring occurred. This period was 305 days. Patients who experienced a PCT during the first 305 days of observation were assigned a value of 1, while those who did not experience one were assigned a value of 0. In the ROC analysis, cutoff values ​​for the CTA predictors were calculated using the Youden method, according to which the cutoff value is selected to be the number that maximizes the sum of the sensitivity and specificity values ​​for the predictor in question.

[0017] For the 11 most optimal significant predictors of the univariate analysis, in addition to cutoff values, sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve (AUC) were calculated. Then, from the 11 CTA characteristics, the 8 most significant PCT predictors were identified. For each, the corresponding score value is indicated in the table. The contribution of each score to the patient's score is proportional to the AUC value of that risk factor.

[0018] For the resulting "Risk Score," the cutoff value calculated by the Youden method was 3 points. The likelihood of PCT events is 7 times higher in those with a score of 3 or more than in those with 3 or less points, since the odds ratio (OR) = 7.2, 95% confidence interval (CI): 2.6-19.7, p < 0.0001. Therefore, it is proposed to use 3 points as the cutoff value. Therefore, if a patient's CTA data analysis results in a score of 3 or more, i.e., at least 3 CTA characteristics whose values ​​exceed the cutoff values, the patient is at high risk of developing PCT. The AUC of the “Risk Score” was 0.77, specificity was 0.63, sensitivity was 0.81, positive predictive value was 0.21, and negative predictive value was 0.97.

[0019] Clinical examples.

[0020] Example 1.

[0021] Patient N., 46, was admitted to the Intensive Care Unit (ICU) of the E.I. Chazov National Medical Research Center of Cardiology with a diagnosis of "Acute myocardial infarction with ST segment elevation of the inferior-posterior localization, dated October 1, 2022." The diagnosis was 1 hour and 10 minutes after the onset of a first attack of intense chest pain. At the prehospital stage, the emergency medical care team recorded ST segment elevations of up to 2 mm in leads II, III, and aVF on the ECG. The patient had no history of any chronic comorbidities, except for obesity. In addition to the typical clinical picture and ECG changes, the diagnosis of acute myocardial infarction (AMI) was confirmed by an increase in the level of highly sensitive troponin to 9503 pg / ml, and the detection of impaired contractility of the left ventricle (LV) in the lower-posterior localization (hypokinesis zones of the basal segment of the inferior wall and the middle segment of the posterior wall of the LV) according to echocardiography data.The patient underwent emergency coronary angiography (CAG), which revealed thrombotic occlusion of the distal segment of the right coronary artery (RCA). Immediately following CAG, thrombus extraction and a series of predilations were performed, after which blood flow through the RCA was restored. However, thrombosis of the posterolateral branch (PLB) and severe stenosis of the posterior descending artery (PDA) persisted. Therefore, PCI with stenting of the PLB with a Promus Elite drug-eluting stent and PCI with stenting of the posterior descending artery (PDA), also with a Promus Elite stent, were performed. During the procedure, the stent in the PDA thrombosed, and all attempts to open the PDA, including with eptifibatide administration, were unsuccessful. In the acute period of the disease, therapy was carried out with aspirin, ticagrelol, eptifibatide, enoxaparin sodium, atorvastatin, anaprilin (with transfer to bisoprolol in the subacute period of the disease), captopril (with transfer to perindopril in the subacute period of the disease).Subsequently, the pain did not recur, blood pressure remained within normal limits, and no significant cardiac rhythm or conduction disturbances were noted according to Holter ECG monitoring. An initial CTA was performed during the subacute phase of myocardial infarction (MI).

[0022] Furthermore, despite the fact that the patient, in accordance with the discharge recommendation, took atorvastatin at the maximum dose of 80 mg per day and his low-density lipoprotein cholesterol (LDL-C) level decreased from 2.17 to 0.97 mmol / L, i.e., was within the target range, and he continued to take dual antithrombotic therapy with aspirin and ticagrelol at standard doses, on January 31, 2023, he developed an acute myocardial infarction (AMI) of the inferior location (the earliest event of the primary endpoint - PCT). The patient was urgently hospitalized at City Hospital No. 67. According to emergency coronary angiography, thrombotic occlusion of the distal RCA with involvement of the PMV was detected; emergency PCI of the RCA with stenting using a YUKON stent with transition to a previously installed stent in the PMV was performed.

[0023] According to the results of the initial CTA of the coronary arteries, after PCI of the symptom-associated lesion, the patient had 2 soft plaques remaining: 1 in the proximal segment of the RCA and 1 in the middle segment of the PVA, which exceeded the cutoff value for the "number of arteries with abscess plaques> 1.5" indicator (1 point). "The maximum length of abscess plaques> 14.5 mm" was noted for the plaque in the proximal segment of the RCA - 17 mm, which also exceeded the cutoff value for this indicator (1.16 points). The same plaque had a "minimum abscess plaque density" of 22 HU, which is also below the cutoff value for this indicator (1.33 points). That is, the total score exceeded the threshold value of 3.0 and amounted to 3.49 on the risk point scale, indicating an increased risk of PCT events in 1 year after the development of the index event - ACS, in this case - AMI.

[0024] Example 2.

[0025] Patient K, 67 years old. On December 22, 2020, the patient first experienced intense chest pain. He called an ambulance. An ECG showed ST segment elevations in the chest leads and the patient was hospitalized in Derbent, where he was diagnosed with "Acute myocardial infarction with ST segment elevation of the anterior wall, septum, and apex of the left ventricle." Echocardiography revealed a hypoakinesis zone in the anterior wall and apex of the left ventricle, confirming the diagnosis. The patient received fibrinolytic therapy with intravenous actilyse, followed by pronounced positive dynamics on the ECG - a decrease in the ST segment in the chest leads to the isobaseline within 30 minutes from the start of drug administration, which is a reliable criterion for successful thrombolysis in the infarction-related coronary artery. CAG was not performed. Standard therapy was carried out with aspirin, clopidogrel, atorvastatin, bisoprolol, and perindopril.The chest pain attacks did not recur, and no signs of circulatory failure or heart rhythm disturbances were observed.

[0026] On January 10, 2021, the patient visited the National Medical Research Center of Cardiology for a routine outpatient examination. According to the initial CTA of the coronary arteries, moderate, "intermediate" stenoses were revealed: in the anterior descending artery (ADA) - 60-65%, 1 diagonal artery (DA) - 65-70%, in the proximal segment of the 1 obtuse marginal artery (OMA) - 60-65%, in the proximal segment of the RCA - 55-60%. Echocardiography revealed an area of ​​contractility impairment in the anterior wall, septum, and apex of the LV. According to stress echocardiography, the test was negative. There were no indications for coronary angiography and stenting. Standard drug therapy was continued.

[0027] Since the end of August 2021, the patient resumed attacks of angina pectoris. From September 25, the attacks sharply increased in frequency, beginning to occur with low exertion, occasionally at rest. On September 30, 2021, an outpatient CTA of the coronary arteries was performed, according to which an increase in the degree of stenosis of the left anterior coronary artery (LAA) in the middle and proximal segments to 80-85% (due to an increase in soft plaque with microcalcifications, remodeling, and suspected development of an intramural hematoma) and in the middle segment of the IDA to 90-95% was revealed. On October 12, 2021, the patient was hospitalized at the National Medical Research Center of Cardiology. At the time of admission, he was taking bisoprolol 2.5 mg, lisinopril 10 mg, amlodipine 5 mg, clopidogrel 75 mg, cardioaspirin 50 mg, rosuvastatin 10 mg, and ezetimibe 10 mg per day. An ECG showed signs of focal cicatricial lesions in the anterior septal and inferior locations (presumably as a consequence of myocardial infarction on December 22, 2020).Echocardiography revealed hypokinetic zones along the anterior and septal walls (in the middle and apical segments) and along the inferior wall (in the apical segment) of the left ventricle. EF was slightly reduced to 47%. Hemodynamically insignificant valvular regurgitation was present. Stress echocardiography revealed a positive test. Initially, a hypoakinesia zone was observed along the anterior septal and anterior walls of the left ventricle (apical and middle segments) extending to the apical segment of the inferior LV wall. At maximum stress, the initial impairment of local LV contractility worsened and expanded, extending to the lateral wall of the left ventricle (apical segment). Unstable angina (the earliest type of PCT) was diagnosed. On October 18, 2021, a coronary angiography (CAG) was performed (90% stenosis of the left anterior coronary artery, 90% stenosis of one atrial coronary artery, and subtotal stenosis of one atrial coronary artery). Immediately after the CAG, PCI was performed with stenting of the atrial coronary artery and left anterior coronary artery using Promus PREMIER drug-eluting stents.

[0028] After the development of the initiating event - AMI, for which fibrinolytic therapy was carried out with a clearly expressed positive effect, a total of 4 soft plaques were detected in the patient: 1 - in the middle segment of the LAD, 1 - in the IDA, 1 - in the proximal segment of the ACA and 1 - in the proximal segment of the RCA, i.e. in 4 arteries, which significantly exceeded the cutoff value for the indicator "number of arteries with ASP> 1.5" (1 point). The ASP located in the LAD was 16 mm in length, i.e. exceeded the cutoff value of the indicator "maximum ASP length> 14.5 mm" (1.16 points). "Total ASP length> 22.5 mm" was 36 mm, exceeding the cutoff value for this indicator (1.17 points). All four plaques showed obstructive stenosis, exceeding the cutoff value for the "number of atherosclerotic plaques with obstructive stenosis >3.5" (1.1 points). The "minimum atherosclerotic plaque density" in the ATC plaque was 12 HU, significantly below the cutoff value for this parameter (1.33 points).Spotty calcifications were detected in two plaques, which also exceeded the cutoff value for the "number of plaques with spotty calcifications >1.5" indicator (1.23 points). For all six indicators listed, the total score was 6.99, which is significantly higher than the cutoff value of 3.0 and indicates a high risk of developing PCT in the first year after the initiating event (AMI).

[0029] Example 3.

[0030] Patient A., 73, was admitted to the Intensive Care Unit (ICU) of Department 1 of the E.I. Chazov National Medical Research Center of Cardiology on August 21, 2022, due to an attack of intense chest pain that occurred for the first time in his life and lasted more than 30 minutes. The diagnosis was "Acute myocardial infarction with ST-segment elevation of the anterior localization." Comorbidities: type 2 diabetes mellitus, obesity, arterial hypertension stage III, stage 3, risk 4. At the time of hospitalization, he was not taking statins or antithrombotic drugs. In addition to the typical clinical picture, the diagnosis of AMI is confirmed by a significant increase in the level of highly sensitive troponin, according to echocardiography data - the detection of a hypoakinesis zone along the anterior wall, septum, apex of the LV, a decrease in LVEF to 47%, and data from urgently performed coronary angiography.A coronary angiography revealed a thrombotic occlusion in the proximal segment of the left anterior dorsal artery (LAD), and after thrombus removal, severe stenosis in the proximal and middle segments of the LAD and in the proximal segment of the first dorsal artery (DA). Emergency PCI with stenting of the affected segments of the LAD and DA was performed. By the time of hospitalization, the patient's lipid profile was within normal limits. Atorvastatin, aspirin, and ticagrelor were prescribed at standard doses and continued to be taken regularly after discharge. Target LDL-C (1.3 mmol / L) and triglyceride (1.19 mmol / L) levels were achieved.

[0031] On September 11, 2022, the patient developed a repeated attack of chest pain. He was hospitalized, diagnosed with a recurrence of anterolateral myocardial infarction (the earliest PCT event), emergency coronary angiography was performed, and PCI with stenting of the circumflex artery (OA) - proximal and middle segments and the proximal segment of the IDA was performed.

[0032] Based on the results of the initial coronary artery CTA after PCI of the symptom-associated lesion, the patient had 2 clearly visible soft plaques: 1 calcified plaque located in the left main coronary artery, 2 soft plaques located in the proximal RCA. Thus, the number of arteries with ASP - 2 - exceeded the cutoff value for this indicator in the risk scoring scale (1 point). The length of the ASP in the RCA corresponded to 16 mm, i.e., exceeded the cutoff value for the "maximum ASP extent" indicator (1.16 points). Finally, the minimum density of this plaque was also below the cutoff value and amounted to 18 HU (1.33 points). Thus, the total score was 3.49, which is higher than the threshold value of 3.0 and indicates a high risk of developing PCT in the first year after the initiating event - AMI.

[0033] Example 4.

[0034] Patient H., 59, was admitted to the Intensive Care Unit (ICU) of the E.I. Chazov National Medical Research Center of Cardiology with a diagnosis of "Acute myocardial infarction with ST-segment elevation of the inferior localization, dated November 26, 2018." Three hours after the onset of an attack of intense chest pain. At the prehospital stage of the emergency hospital, the ECG recorded ST-segment elevations in leads II, III, and aVF up to 2 mm. The patient has a history of arterial hypertension for 3 years and hyperlipidemia. Prior to hospitalization, he did not receive antithrombotic or lipid-lowering therapy.In addition to the typical clinical picture and ECG changes, the diagnosis of acute myocardial infarction (AMI) was confirmed by an increase in the level of highly sensitive troponin, detection of a localized impairment of LV contractility in the inferior localization (hypokinesis of the basal segment of the LV inferior wall) according to echocardiography, and emergency coronary angiography data: occlusion was detected in the proximal segment of the RCA, the left coronary artery (LCA) was stenotic by 60%, the LAD in the proximal segment was stenotic by 50%, in the middle segment - by 65-70%, and the OA in the middle segment was narrowed by 40%. Emergency TBCA with stenting of the proximal RCA segment with a Resolute Integrity drug-eluting stent was performed. The patient received standard antithrombotic therapy with acetylsalicylic acid and ticagrelol and lipid-lowering therapy with atorvastatin 40 mg / day during hospitalization and after discharge. Target LDL-C values ​​of 1.34 mmol / L (baseline: 3.71 mmol / L) were achieved.

[0035] On November 10, 2019, the patient experienced a resumption of progressive angina attacks: the attacks tended to increase in frequency and occur with low exertion for a week. On November 20, 2019, the patient was hospitalized at the National Medical Research Center of Cardiology. An ECG showed T-wave dynamics from positive to negative in lead III. According to stress echocardiography, a test for latent coronary insufficiency was positive: initially, echocardiography data revealed an area of ​​slight hypokinesia along the inferior wall of the LV (basal and partially middle segments). At maximum exertion, in addition to chest pain, a new area of ​​hypokinesia appeared along the anteroseptal, anterior, and anterolateral walls of the LV (apical and middle segments). Unstable angina was diagnosed (the earliest PCT event). According to the CAG data from 11 / 26.2019: The LAD is 60% stenotic in the proximal segment, 70-80% stenotic in the middle segment, 50% stenotic in the middle third of the OA, 60% stenotic at the ostium of the RCA, and 50% stenotic at the ostium of the LAD, indicating increasing stenosis of the coronary arteries. PCI was performed with stenting of the proximal and middle segments of the LAD with 2 stents and the left main coronary artery with 1 Promus Premier drug-eluting stent, as well as kissing balloon angioplasty of the left main coronary artery-LAD and left main coronary artery-OA.

[0036] Based on the results of the initial coronary artery CTA after PCI of the symptom-associated lesion, the patient had 2 combined plaques remaining: 1 in the trunk extending to the proximal segment of the left anterior coronary artery and 1 in the middle segment of the left anterior coronary artery, which exceeded the cutoff value for the "number of arteries with atherosclerotic plaques" indicator (1 point). The same plaque in the trunk had a "minimum atherosclerotic plaque density <29.1 HU" - 18 HU, which is also below the cutoff value for this indicator (1.33 points). A low-density area of ​​less than 30 HU was also detected in the plaque in the left anterior coronary artery, i.e., according to the "number of plaques with a low-density area <30 HU" indicator, the patient is assigned an additional point on the scoring scale. Thus, the total score exceeded the threshold value of 3.0 and amounted to 3.33 points on the risk score scale, indicating an increased risk of PCT events in 1 year after the development of the index event - ACS, in this case - AMI.

[0037] Example 5.

[0038] Patient R., 69, was admitted to the Emergency Hospital in the First Clinical Department of the National Medical Research Center of Cardiology after a first-ever attack of intense chest pain. She had a diagnosis of ST-segment elevation acute coronary syndrome (ACS). She had no history of any significant chronic illnesses. Prior to hospitalization, she had not received any antithrombotic or lipid-lowering therapy. In addition to the typical clinical picture and ECG changes in the form of ST segment elevations in leads I, aVL, V1-V6, the diagnosis of AMI was confirmed by an increase in the level of highly sensitive troponin to 324 pg / ml, according to echocardiography data, a violation of local contractility of the LV (hypoakinesia) was detected along the anterior septal, anterior walls of the LV (middle, apical segments) with a transition to the apex of the LV, emergency CAG data: occlusion of the LAD in the proximal section, stenosis of the left coronary artery trunk by 30%, stenosis of the OA in the proximal segment by 40-50%, stenosis of the RCA in the middle segment by 40%.PCI with stenting of the proximal and mid-LAD ​​segments using a Xience Alpine drug-eluting stent was performed. Standard antithrombotic therapy with antiplatelet agents (acetylsalicylic acid and ticagrelol) and lipid-lowering therapy with atorvostatin at a continuous dose of 80 mg / day were administered. Against this background, LDL-C levels decreased from 2.44 mmol / L to a target value of 1.2 mmol / L.

[0039] Since the beginning of May 2023, the patient resumed having attacks of angina with little physical exertion. On an outpatient basis, on May 24, 2023, a repeat CTA of the coronary arteries was performed, the results of which revealed a 90% stenosis above the stent in the proximal segment of the LAD, a plaque in the left coronary artery (LCA) stenotic by 50%, a 40% stenosis at the orifice of the left coronary artery (OA), and plaques in the proximal and middle segments of the RCA, stenotic by 30% and 40%. She was hospitalized on June 2, 2023, at the E.I. Chazov National Medical Research Center of Cardiology. Based on the results of coronary angiography (CAG) on June 5, 2023, the patient was found to have 80-90% stenosis in the proximal segment of the left anterior coronary artery (LAA), in the left main coronary artery (LMCA), left coronary artery (OA), and right coronary artery (RCA) - without hemodynamically significant stenoses. Based on the examination results, the primary diagnosis was: “Coronary artery disease. Functional class III angina. Postinfarction cardiosclerosis (anterior ST-segment elevation myocardial infarction on October 14, 2022). Atherosclerosis of the aorta and coronary arteries.Percutaneous coronary intervention with stenting of the proximal anterior descending artery with a Xience Alpine stent on October 14, 2022. On June 5, 2023, PCI was performed with stenting of the proximal LAD segment with a SYNERGY drug-eluting stent (the earliest PCT event). Standard lipid-lowering and antithrombotic therapy was continued.

[0040] According to the results of the initial CTA of the coronary arteries, after PCI of the symptom-related lesion, the patient had 2 combined plaques and 1 soft plaque located in the left main coronary artery, the proximal segment of the left adrenal artery, and the proximal segment of the coronary artery, which exceeded the cutoff value for the "number of arteries with atherosclerotic plaques> 1.5" indicator (1 point). "The total length of atherosclerotic plaques> 22.5 mm" was 23 mm, which exceeded the cutoff value for this indicator (1.16 points). For all 3 atherosclerotic plaques, the "minimum density" was below the cutoff value, and the lowest value corresponded to 17 HU (1.33 points). Also, an area with a low density of less than 30 HU was detected in the plaque in the left main coronary artery, i.e. According to the "number of plaques with a low-density area <30HU>0.5" risk score, the patient is assigned an additional 1 point. "Number of plaques with spotty calcifications >1.5" is assigned 2, which in our patient exceeded the cutoff value for this indicator (1.23 points).That is, the sum of points exceeded the threshold value of 3.0 and amounted to 5.72 on the risk point scale, indicating an increased risk of occurrence of PCT events in 1 year after the development of the index event - ACS, in this case - AMI.

[0041] Thus, the advantage of the proposed invention is an increase in the efficiency of predicting adverse cardiovascular events, i.e. the progression of a socially significant disease, the occurrence of repeated heart attacks, strokes, the need for expensive procedures (PCI, aortocoronary bypass / mammary-coronary bypass), death from ischemic heart disease, acute coronary syndrome, which makes it possible to:

[0042] - promptly identify patients with an increased risk of such outcomes, providing them with increased professional control over examination and treatment, selection of pathogenetic, optimally personalized therapy aimed at restoring coronary blood flow and myocardial metabolism; prevention of the progression of the atherosclerotic process and thrombus formation in the coronary arteries, arteries supplying blood to the brain and other vital organs.

[0043] - to identify patients with non-obstructive coronary artery disease but an increased risk of adverse outcomes according to our "Risk Score" who are not typically eligible for enhanced monitoring by specialists for follow-up and optimization of targeted preventive measures aimed at preventing serious complications and premature mortality in the population.

[0044] - to reduce the large financial costs of healthcare associated with expensive treatment of delayed serious complications in patients who have suffered acute coronary syndrome.

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