Arterial hypertension in adults. Clinical guidelines 2020

Patient Adherence and Duration of Continuous Treatment With Various Arbs in Patients With Uncomplicated Arterial Hypertension in the USA Based on The Analysis of the Truven Health Analytics MarketScan Database

AIM

To discuss two aspects that can be used to improve the adherence to therapy in patients with arterial hypertension (AH): 1) which of the angiotensin II receptor blockers (ARBs) provides the highest adherence rates; 2) how various factors influence adherence rates.

MATERIAL AND METHODS

An analysis of one of the world's largest clinical practice databases, Truven Health Analytics MarketScan (currently Merative MarketScan), was performed. The analysis included data on patients of both sexes aged 30 to 65 years who had been diagnosed with uncomplicated AH (at least once between March 1, 2012 and January 1, 2018) and prescribed monotherapy with one of ARBs. The exclusion criteria were heart failure and the treatment with two or more ARBs (simultaneously or sequentially) during the treatment period. Ultimately, the study included 717,099 patients with uncomplicated AH, who were divided into four groups based on the prescribed drug: azilsartan (n=4276), candesartan (n=6023), losartan (n=586,857), and valsartan (n=119,943). Adherence to treatment was evaluated by two parameters: duration of continuous therapy and medication possession ratio (MPR). The individual effect of each factor (specific ARB used for therapy, patient gender, age, initial ARB dose, patient co-payment per day of treatment) on the adherence to treatment was assessed using a regression analysis.

RESULTS

The adherence to the ARB therapy was generally high. The MPR was the lowest in the azilsartan group and the highest in the candesartan group. However, the parameters that potentially influenced both the MPR and the duration of continuous therapy (patient's gender and age, initial ARB dose, co-payment size) differed significantly between the groups receiving different ARBs. The regression analysis showed that both adherence parameters and the duration of continuous therapy were higher in patients receiving candesartan than in patients receiving azilsartan, losartan or valsartan, when the effect on the adherence of other factors available for study (age, gender, initial dose of the drug, and the absolute size of co-payment for a day of therapy) was excluded. The lowest adherence to therapy was observed in the azilsartan treatment group (p<0.01).

CONCLUSION

The study provided data for comparing the adherence of patients with uncomplicated AH to the therapy with different ARBs. Further study of adherence to treatment will provide additional data that will allow an optimal selection of drugs for the treatment of AH in patients with potentially poor adherence.

Original Moxonidine and Generics: Where is the Edge of Difference?

AIM

To compare the efficacy of adding original moxonidine and its generics to previous ineffective antihypertensive therapy in patients with poorly controlled arterial hypertension (AH).

MATERIAL AND METHODS

This observational prospective non-randomized study included 120 patients with poorly controlled blood pressure on the previous antihypertensive therapy. All patients underwent clinical evaluation, including anthropometric and laboratory indexes, and 24-hour blood pressure monitoring (24-h BPM) at baseline and after 12 weeks of observation. Office systolic and diastolic blood pressure (SBP and DBP) and heart rate (HR) were recorded after 4 and 12 weeks of treatment. During the observation period, 4 equal groups were formed: group 1, Physiotens was added to the treatment; group 2, Moxonitex; group 3, Moxonidine SZ; and group 4, Moxonidine Canon. Statistical analysis was performed with the StatTech v.4.2.7 software (© OOO StatTech, Russia).

RESULTS

After 4 weeks of therapy, the BP target was achieved significantly more frequently in group 1 (63% of patients) compared to groups 2 (36.7% of patients), 3 (16.7% of patients), and 4 (16.7% of patients) (p<0.05). At 12 weeks, office SBP, DBP, and HR were significantly decreased in all groups, but the decrease was significantly greater in group 1. The therapy was associated with a more pronounced decrease in all studied 24-h BPM parameters in the Physiotens group than in other groups, as well as with a significantly more frequent normalization of the 24-h BP profile, in 66.7% of patients vs. 46.7%, 33.4%, and 23.2% of patients in groups 2, 3, and 4, respectively.

CONCLUSION

The treatment with original moxonidine demonstrated advantages over generic drugs in terms of achieving the BP goal, reducing office BP and HR, and improving 24-h BPM parameters.

[Chronic kidney disease and chronic heart failure: impact on prognosis and choice of pathogenetic therapy]

AIM

To evaluate the impact of a decrease in glomerular filtration rate (GFR) on the prognosis of patients with chronic heart failure (CHF), to analyze real clinical practice regarding the frequency of prescribing pathogenetic therapy for CHF, achieving target dosages depending on the gradation of GFR in patients included in the CHF Register of the Tyumen region.

MATERIALS AND METHODS

The analysis included medical data of 4077 patients (1662 men and 2415 women) with NYHA class I-IV CHF who underwent examination and treatment in medical organizations of the Tyumen region for the period from January 2020 to May 2023. Criteria for inclusion in the register: proven heart failure. Chronic kidney disease (CKD) was assessed by GFR calculated using the CKD-EPI formula (ml/min/1.73 m2). The primary end point was defined as death from all causes.

RESULTS

GFR<60 ml/min/1.73 m2 was recorded in 34.6% of patients, more common in women (40.2 and 26.6%, respectively; p<0.001). When dividing patients into phenotypes according to LVEF, no statistically significant differences were found in the distribution of patients according to GFR. In patients with HFrEF and HFpEF GFR<45 ml/min/1.73 m2 was associated with an increased risk of meeting the endpoint. Analysis of prescribed pathogenetic therapy showed that in patients with HFrEF, the frequency of prescription of ACE inhibitors, â-blockers and MRA decreased (p=0.023, 006 and 0.01, respectively), and ARNI, on the contrary, increased with a decrease in GFR (p=0.026). In patients with HFpEF, a similar trend towards a decrease in the frequency of prescription of ACEIs and MCBs with a decrease in GFR (p<0.001) remained, but it was compensated by an inversely proportional increase in the frequency of prescription of ARBs (p<0.001). 100% of the target dosage is achieved in more than 90% of patients taking MRA across the entire LVEF range. While for â-blockers and ARNI/ACE/ARB the percentage of patients receiving the full therapeutic dosage of drugs is significantly lower. When analyzing target dosages of pathogenetic drugs, gradations of achieved doses were distributed evenly throughout the entire range of GFR.

CONCLUSION

GFR<60 ml/min/1.73 m2 occurs in every 3 patients with CHF across the entire range of LVEF. A decrease in GFR worsens the prognosis of patients with both HFrEF and HFpEF, increasing in direct proportion with the severity of the stage of CKD. Inclusion of patients in the monitoring program within the framework of the CHF service allows the treatment to be significantly brought closer to optimal drug therapy, at the same time, certain efforts are required to overcome difficulties with titration to target dosages.

[Features of the Course of Arterial Hypertension in the Era of the COVID-19 Pandemic: Common Pathogenetic Links Between Hypertension and SARS-CoV-2]

The aim of this review was to present the mechanism of infection with severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) and its possible effect on the course of arterial hypertension. Another aim was to evaluate the relationship of the renin-angiotensin-aldosterone system with the pathogenetic stages of infection caused by SARS-CoV-2 virus.

Features of The Dynamics of Profibrotic Markers and Regression of Left Ventricular Hypertrophy After Renal Denervation in Patients With Resistant Hypertension and Stenosing Atherosclerosis of the Coronary Arteries

AIM

To compare the changes in serum concentrations of matrix metalloproteinases (MMPs) and their tissue inhibitor (TIMP) to the dynamics of blood pressure (BP) and parameters of left ventricular hypertrophy (LVH) 6 months after renal denervation (RD) in patients with resistant arterial hypertension (RAH) and complicated coronary atherosclerosis.

MATERIAL AND METHODS

In 22 RAH patients with complicated coronary atherosclerosis (revascularization and/or history of myocardial infarction (MI)), 24-hour BP monitoring, echocardiography, and measurement of blood MMPs and TIMP were performed at baseline and six months after RD. The comparison group consisted of 48 RAH patients without a history of coronary revascularization or MI.

RESULTS

In 6 months after RD, BP was decreased comparably in both groups. In the group of complicated atherosclerosis, there were no significant changes in profibrotic markers or LVH parameters. Thus, at baseline and after 6 months, the values of the studied indicators were the following: left ventricular myocardial mass (LVMM) 233.1±48.1 and 243.0±52.0 g, LVMM index 60.6±14.5 and 62.8±10 .9 g/m2.7, proMMP-1 4.9 [2.1; 7.7] and 3.6 [2.0; 9.4]  ng/ml, MMP-2 290.4 [233.1; 352.5] and 352.2 [277.4; 402.9] ng/ml, MMP-9 220.6 [126.9; 476.7] and 263.5 [82.9; 726.2] ng/ml, TIMP-1 395.7 [124.7; 591.4] and 424.2 [118.2; 572.0] ng/ml, respectively. In the comparison group, on the contrary, there was a significant decrease in LVMM from 273.6±83.3 g to 254.1±70.4 g, LVMM index from 67.1±12.3 to 64.0±14.4 g/m2.7, proMMP-1 from 7.2 [3.6; 11.7] to 5.9 [3.5; 10.9] ng/ml, MMP-2 from 328.9 [257.1; 378.1] to 272.8 [230.2; 343.2] ng/ml, MMP-9 from 277.9 [137.0; 524.0] to 85.5 [34.2; 225.9] ng/ml, and the MMP-9/TIMP-1 ratio from 0.80 [0.31; 1.30] to 0.24 [0.07; 0.76]. The BP dynamics in this group was inversely correlated with MMP-2 at 6 months (r=-0.38), and the MMP-9/TIMP-1 ratio was correlated with LVMM and the LVMM index at baseline (r=0.39 and r=0.39) and at 6 months (r=0.37 and r=0.32). The change in TIMP-1 from 543.9 [277.5; 674.1] to 469.8 [289.7; 643.6] ng/ml was not significant (p=0.060).

CONCLUSION

In RAH patients with complicated coronary atherosclerosis, the dynamics of profibrotic biomarkers and LVH parameters after RD was absent despite the pronounced antihypertensive effect, probably due to the low reversibility of cardiovascular remodeling processes or more complex regulatory mechanisms of the MMP system.

Lipitension and cardiometabolic risk factors in young people

Aim. To study the relationship of lipitension and cardiometabolic risk (CMR) factors in young people.

Material and methods. The case-control study on general obesity (GO) (overweight — 33,3%, GO — 33,3%) included 191 patients (Me=35,0 [30,0-39,0] years; F/M=97(50,8%)/94(49,2%)) without cardiometabolic diseases, comparable by sex and age. The prevalence and characteristics of lipitension were studied, taking into account the features of dyslipidemia and increased blood pressure (BP). Depending on the presence of lipitension, 2 groups were identified in which the CMR factors were studied: GO and abdominal obesity (AO), visceral fat, prediabetes, insulin resistance, increased C-reactive protein (CRP), hyperuricemia, glomerular filtration rate changes. Data were processed using SPSS Statistics 26.

Results. Overall, the incidence of increased BP was 36,1%, hypertension (HTN) — 16,2%, and dyslipidemia — 73,3%. Lipitension was diagnosed in 25,1% of patients. At the same time, increased BP and HTN without combination with dyslipidemia were detected less frequently (13,1% and 5,2%, respectively). Dyslipidemia without increased BP and HTN, on the contrary, is more common (48,2%). Lipitension is more often diagnosed in men than in women — 32 (66,7%) and 16 (33,3%), p=0,005; [odds ratio=2,6; 95% confidence interval: 1,32-5,18]. In patients with lipitension, 43,8% were diagnosed with HTN, while the remaining 56,2% had BP ≥130/85 mm Hg. In the structure of dyslipidemia in lipitension, 79,2% had abnormalities in ≥2 lipid parameters, of which increased levels of low-density lipoprotein cholesterol (LDL-C) and hypercholesterolemia (78,3%) were most often detected. Persons with lipitension more often had AO (31,2%), increased glycated hemoglobin (HbA1c) >6% (39%) and insulin resistance (36,2%) than those without lipitension (p=0,026, p=0,018, p=0,044, respectively). With lipitension, a higher level of visceral fat (Me=8 [6-9] units) and HbA1c (Me=5,6 [5,1-6,0]%) was established than without it (Me=6 [4-9]U and Me=5,4 [5,1-5,9]%, respectively p=0,000 and p=0,018).

Conclusion. Increased BP and HTN are more often found in combination with dyslipidemia than as an independent risk factor. In lipitension, the largest number of patients had ≥2 lipid metabolism disorders, most often represented by increased LDL-C and hypercholesterolemia. The presence of lipitension was associated with AO, increased HbA1c, and insulin resistance.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Consensus statement on the management of patients with asymptomatic hyperuricemia in general medical practice

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Predictors of the Development of Associated Clinical Conditions in Working-Age Patients With Cardiovascular Risk Factors in Conditions of High Adherence to Treatment

AIM

To determine predictors for the development of associated clinical conditions (ACC) in patients of working age with cardiovascular risk factors (CVRFs) in the conditions of high compliance with the treatment and healthy lifestyle (HLS).

MATERIAL AND METHODS

The study included 364 patients with CVRFs without target organ damage and a history of ACC. Mean age was 42.24±8.08 years. Patients were examined in consistency with the Russian Society of Cardiology (RSC) 2020 guidelines for arterial hypertension and chronic heart failure. The follow-up period was 6.45±0.42 years. 350 patients completed the study, 9 patients died during the follow-up period, and 5 were lost to follow-up. Patients were divided into two groups based on the development of ACC. The first group consisted of 56 (16%) patients with verified ACC, the second group included 294 (84%) patients without ACC.

RESULTS

Regression logistic and correlation analyses confirmed the prognostic significance for the development of ACC by 12 indicators. The risk of ACC in smokers was increased more than 7 times (odds ratio (OR) 7.44, 95% confidence interval (CI): 3.42-16.21), and when type 2 diabetes mellitus (DM) developed, more than 9 times (OR 9.47, 95% CI: 4.36-20.59); with chronic kidney disease (CKD), more than 6 times (OR 6.75, 95% CI: 3.41-13, 37); with a history of COVID-19 (COronaVIrus Disease 2019) pneumonia, 7 times (OR 7.11, 95% CI: 3.04-16.58); with left ventricular hypertrophy (LVH), 6 times (OR 6, 35, 95% CI: 3.14-12.83); with CAVI index>7.2, almost 3 times (OR 2.69, 95% CI: 1.48-4.86); with PVWcf (carotid-femoral pulse wave velocity) >13 m/s, more than 5 times (OR 5.61, 95% CI: 2.79-11.28); with R-AI index (augmentation index) >1, more than 2 times (OR 2.26, 95% CI: 1.3-3.9); and with an increase in the indexed left atrial volume (ILAV) >27 ml/m2, more than 8 times (OR 8.80, 95% CI: 4.61-16.79). In the presence of polymorphisms in the form of homozygosity for the minor allele of the AGT gene (Thr174Met, rs4762), the risk of developing ACC increased 14 times (OR 14.13, 95% CI: 4.69-42.57), the APOE gene (Cys130Arg, rs429358), 11 times (OR 11.18, 95% CI: 4.18-29.93), and in the intron of the PRARα gene (rs4253778), 8 times (OR 8.11, 95% CI: 3.75-17.53).

CONCLUSION

The development of ACC in patients with high compliance with treatment and a healthy lifestyle is associated with smoking, type 2 diabetes and CKD, a history of COVID-19 pneumonia, LVH, increased ILAV >27 g/m2, more pronounced arterial stiffness assessed by an increase in CAVI indices >7.2, R-AI >1, and PWVcf >13 m/s; and with the presence of polymorphism of the AGT, APOE and PPARα genes in the form of homozygosity for the minor allele.

Possibilities of Using the National Electronic Data Syetstem in Assessing the Control of Arterial Hypertension at The Primary Health Care Level in the Kyrgyz Republic Using the Example of a Single Family Medicine Center

AIM

To determine the capabilities of the National Electronic System for collecting quantitative data necessary to assess the quality of management and effectiveness of arterial hypertension (AH) control at the primary health care (PHC) level and to develop indicators and possibilities of their use for a standardized report on the quality of AH management and control at the PHC level in the Kyrgyz Republic.

MATERIAL AND METHODS

Data from electronic outpatient records were processed for all registered patients of a pilot family medicine center (FMC) that was selected randomly. The registered patient group consisted of 91,226 people older than 18 years, including 37,740 men and 53,486 women. The data obtained during contact with a patient was entered by the family doctor into the electronic outpatient record and automatically forwarded to the center that collected and aggregated the data. To monitor AH control, 11 indicators were developed and evaluated. The indicators were divided into 3 groups: indicators for identifying AH, indicators for the quality of AH patient management, and indicators for the effectiveness of AH control.

RESULTS

In total, 26,206 patients (7,933 men and 18,273 women) visited the FMC during a year, and blood pressure (BP) was measured in 71.4% of them. In 2022, 5,072 patients (5.6% of the registered group) visited the FMC for AH, including 1,539 men and 3,533 women (4.1 and 6.6% of the registered patient group, respectively; p<0.001). The proportion of patients with AH who, according to the clinical protocol, had their BP measured 2 times a year or more, was 81.4% and was slightly higher for women than for men (82.3% and 79.1%, respectively; p<0.01). 38.7% of AH patients received antihypertensive drugs. Lipid-lowering therapy was prescribed to 23.5% of AH patients. The proportion of AH patients taking acetylsalicylic acid was higher, 36.3% for the whole group, including 34.1% for men and 37.2% for women (p<0.05). The efficacy of AH treatment was 62.8%.

CONCLUSION

Any monitoring system has limitations for the amount of useful data that can be obtained ensuring their proper quality. Taking this into account, two major indicators are suggested to use for evaluating the effectiveness of AH control at the PHC level: 1) the number of AH patients who have achieved the BP goal; 2) the number of AH patients who visited a medical institution (health care facility) during a calendar year relative to the number of registered patients (AH detectability).

[Physical methods of correction of arterial hypertension: modern concepts. (A literature review)]

Arterial hypertension is a major risk factor for cardiovascular disease, affecting a large proportion of the population worldwide. The study of the listed literature made it possible to assess the effectiveness and necessity of physical exercise in the treatment of hypertension syndrome, including various types of exercise, intensity, duration, and frequency, since drug treatment is not enough for successful therapy. To prevent and treat hypertension, a comprehensive approach is required, including aerobic exercise, which will lower blood pressure by dilating blood vessels.

[Theory of centralized aerobic-anaerobic energy balance compensation and non-pharmaceutical treatment methods of arterial hypertension]

Several chronic non-communicable diseases are associated with arterial hypertension and are closely related to increased blood pressure. The theory of centralized aerobic-anaerobic energy balance compensation (TCAAEBC) was formulated in connection with the above-mentioned processes. This theory, including the hypothesis of the «egoistic brain», is a broader concept. The key point of TCAAEBC is hypoxic anaerobic metabolism, which affects reflex vascular zones, including the neurons of the respiratory and cardiovascular centers of the rhomboid fossa of the medulla oblongata. Hypoxia correction using manual techniques, physical exercises, and other non-pharmaceutical methods under certain conditions can stabilize the level of blood pressure and has a curative effect in the case of arterial hypertension syndrome.

Trends in the dynamics of morbidity and mortality from hypertension in the Republic of Kazakhstan from 2010 to 2019

OBJECTIVE

Aim: The purpose of the research is to study trends in the dynamics of morbidity and mortality from arterial hypertension in the Republic of Kazakhstan for 2010-2019.

PATIENTS AND METHODS

Materials and Methods: Due to the interdisciplinary nature of the study, a set of methods was used: analytical, graph-analytical, statistical, sociological, clinical and economic analysis, organizational experiment.

RESULTS

Results: The survey of 318 hypertension patients highlighted a common profile: hypertensive men aged 45-59, smokers, alcohol drinkers, urban dwellers, married with children, industrially employed, physically active at their country house, and facing stress. Gender differences showed 74.4% of hypertensive women were over 50, while a fifth of men were under 45, with higher risk factors in men: smoking (1.87), alcohol (2.53), occupational hazards (2.76), and harsh climates (2.54).

CONCLUSION

Conclusions: The analysis findings reveal noteworthy trends within the hypertension patient population in Kazakhstan. Despite a decline in hypertension prevalence and initial occurrences, along with reduced relative hospitalization rates between 2010 and 2019, mortality linked to hypertension-related causes and the occurrence of heart attacks have remained relatively steady in recent times.

[Influence of the method of manual-physical correction on autonomic regulation in patients with essential arterial hypertension]

One of the methods of non-drug treatment of essential arterial hypertension, is manual, osteopathic effects on the spine, primarily the cervical spine. Despite the absence of these methods in clinical guidelines for essential arterial hypertension, they continue to develop and improve. One of the promising areas is manual-physical correction with an effect on the cervical spine and subsequent strengthening of the muscle corset with the help of physical exercises (method of A.Yu. Shishonin). One of the supposed mechanisms for reducing blood pressure (BP) in this case is the effect on the autonomic nervous system (ANS). In the course of the study, which was based on the study of heart rate variability (HRV), the presence of pronounced signs of a decrease in sympathetic influences and activation of the parasympathetic nervous system was shown. The parameters of statistical linear analysis (standard deviation of NN intervals; stress index, etc.) and the wave spectrum shifted towards sympathicotonia during therapy using the method of A.Yu. Shishonin. The HRV data were obtained against the background of a decrease in blood pressure and a decrease in heart rate (HR), which suggests the impact of manual physical correction on the ANS as one of the key mechanisms mediating its effect.

[The dynamics of 24-hour arterial pressure monitoring with manual and physical exposure to the cervical spine (A. Shishonin method) in patients with essential arterial hypertension]

One of the most probable and controversial hypotheses regarding the etiology of essential arterial hypertension, is the increase in arterial pressure due to intracranial ischemia, for various reasons, particularly because of cervical osteochondrosis. The daily arterial blood pressure dynamics is of interest when attempting non-pharmacological induced correction of arterial pressure by manual and physical effects on the cervical spine.

OBJECTIVE

To evaluate daily arterial pressure dynamics in patients with essential arterial hypertension who received non-pharmacological treatment by manual-physical action on the cervical spine (A.J. Shishonin method).

MATERIAL AND METHODS

The main group consisted of 120 patients (61 men and 59 women, mean age 59.3±8.5 and 59.8±8.2 years respectively) with pre-hypertension or hypertension 1st degree (systolic AD in the range from 135 to 159 mm Hg. or diastolic AD from 85 to 99 mm Hg. All patients had signs of impaired blood flow through the vertebral arteries in the ultrasound (US) examination. The control group (comparison group) was formed from patients comparable by sex and age. The participants of the study groups had a low propensity to use pharmaceuticals and refused to take medicines. Patients of the studied (main) group were submitted to manual-physical correction with effect, mainly, on the cervical spine by method A.Yu. Shishonina. The technique consists of two stages: 1) manual action to improve blood; 2) exercise to form a muscular corset to maintain the effect. Patients in the control group did not receive targeted therapy. All patients were analyzed daily blood pressure profile through daily 24-hour arterial pressure monitoring technique.

RESULTS

As a result of the therapy, a reliable decrease in the mean daily systolic arterial pressure of 140.1±3.9 mm Hg was recorded up to 129.2±3.8 mm Hg (p<0.05), as well as day and night systolic arterial pressure. Verified reduction of variability of systolic and diastolic arterial pressure in the process of manual-physical correction, both during day and night. The reliable movement of the index of time of hypertension during the day is recorded only for systolic arterial pressure, which decreased from 43.0±3.4 to 24.1±2.5% (p<0.01). Also, after the course of manual-physical correction in patients of the studied group is recorded a reliably lower rate of morning diastolic arterial pressure rise, differing by 40% - with 9.7±1.1 mm Hg per hour to 5.5±1.3 mm Hg per hour (p<0.01) and systolic arterial pressure from 14.4±1.9 to 7.3±1.9 (p<0.01).

CONCLUSION

Manual-physical correction in patients with degenerative-dystrophic lesions of the spine, has a hypotensive effect on most known indicators of 24-hour arterial pressure monitoring arterial pressure monitoring.

Pharmacogenetic markers of development of angioneurotic edema as a secondary side effect to enalapril in patients with essential arterial hypertension

BACKGROUND

Angioneurotic edema is the most dangerous complication in angiotensin-converting enzyme inhibitors (ACEIs) therapy. Based on the current data, the clinical and genetic predictors of angioedema development are still understudied, which demonstrates the relevance of this study.

OBJECTIVE

To reveal the pharmacogenetic predictors of the angioedema as a secondary side effect to enalapril in patients with essential arterial hypertension.

METHODS

The study enrolled 111 subjects randomized into two groups: study group, patients with the angioedema as a secondary side effect to enalapril; and control group, patients without adverse drug reaction. All patients underwent pharmacogenetic testing.

RESULTS

An association between the development of the angioneurotic edema and the genotypes AA rs2306283 of gene SLCO1B1, TT rs4459610 of gene ACE, and CC rs1799722 of gene BDKRB2 in patients was revealed.

CONCLUSION

The findings justify further investigations of the revealed genetic predictors of angioedema with larger-size patient populations.

[Cognitive impairment in patients with arterial hypertension]

Arterial hypertension (AH) is a leading risk factor for cardiovascular diseases including cerebrovascular complications. Strokes and/or vascular cognitive impairment (VCI) are considered as a clinical sign of brain damage as a target organ in hypertension. To identify and assess the severity of VCI, patients with hypertension should undergo a neuropsychological assessment. Neuroimaging confirm the vascular origin of cognitive impairment. Patient management should include antihypertensive therapy along with neuroprotection. Among different neuroprotective therapy, ethylmethylhydroxypyridine succinate (mexidol) is one of medication with serious evidence of clinical efficacy.

[Efficacy of manual correction of cervical spine osteochondrosis in the treatment of arterial hypertension syndrome and prediabetes]

Cardiovascular diseases and diabetes mellitus, debuting as arterial hypertension (AH) syndrome and prediabetes, are common types of chronic non-communicable processes, that are the leading cause of death in the world. The main treatment method for above mentioned disorders, according to the current guidelines, is pharmacotherapy. However, it is possible to effectively apply non-pharmacological correction methods, aimed at the probable etiological factor and inversive mechanism involved in AH maintenance, in the early stages when no permanent changes are maintaining a high level of blood hypertension (BH) and glycemia. Frequently, this mechanism is hypoxia in the vertebral arteries system due to cervical spine osteochondrosis.

OBJECTIVE

To evaluate the therapeutic effect of non-pharmacological methods of restoring brainstem blood supply in patients with AH and prediabetes.

MATERIAL AND METHODS

The number of patients equal 125 (57 men and 68 women, mean age 63.3±11.5 and 65.4±11.8 y.o., respectively) with prediabetes and 1st degree of AH without target organs damage, among whom 102 patients with prehypertension or 1st degree of hypertension and 24 ones with 2nd degree of hypertension, were examined. The original method of manually restoring brainstem blood supply developed in the Shishonin's Clinic was applied to all patients. The control group included patients with the same disorder, who did not receive manipulations. Blood pressure (BP) measurement, ultrasound and triplex ultrasonography of vertebral arteries, biochemical blood test, and estimation of glycemia and glycated hemoglobin were performed.

RESULTS

All patients of the study group had decreased levels of systolic BP (by 23.8±10.7 mm Hg for men and 32.8±11.9 mm Hg for women), an increase of flow velocity in vertebral arteries (by 20.6±7.5 and 21.5±7.2 cm/s, respectively), a decrease of glycated hemoglobin concentration (by 0.32±0.51 and 0.34±0.41%, respectively). In the comparison group, there were no patients with improvement in these indicators.

CONCLUSION

The effectiveness of the author's manual method of cervical spine osteochondrosis correction in the reduction of BP and glycemia levels in the early stages of the disease is shown.

[Russian eligibility criteria prescribing menopausal hormonal hormones therapy for patients with cardiovascular and metabolic diseases. Consensus document of the Russian Cardiological Society, Russian Society of Obstetricians and Gynecologists, Russian Association of Endocrinologists, Eurasian Association of Therapists, Association of Phlebologists of Russia]

Menopausal symptoms can disrupt the life course of women at the peak of their career and family life. Currently, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormonal therapy is the fear of doctors who are afraid of doing more harm to patients than good. Caution is especially important when it comes to women with underlying health conditions. Moreover, it should be recognized that there is a lack of high-quality research regarding the safety of MHT for major chronic non-infectious diseases and common comorbid conditions. The presented consensus document analyzed all currently available data obtained from clinical trials of various designs and created a set of criteria for the acceptability of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, doctors of various specialties who advise women in menopause will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real practice.

[Russian Eligibility Criteria for Prescribing Menopausal Hormone Therapy to Patients With Cardiovascular and Metabolic Diseases. Consensus Document of RSC, RSOG, RAE, EUAT, RAP]

Menopausal symptoms can impair the life of women at the peak of their career and family life. At the present time, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormone therapy is the fear of physicians to do more harm to patients than good. Caution is especially important when it comes to women with concurrent diseases. Moreover, it should be recognized that there is a shortage of high-quality research on the safety of MHT for underlying chronic non-infectious diseases and common comorbidities. The presented consensus analyzed all currently available data from clinical trials of various designs and created a set of criteria for the appropriateness of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, physicians of various specialties who advise menopausal women will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real-life practice.

Pharmacogenetic predictors of development of secondary to enalapril dry cough in hypertensive patients

OBJECTIVES

Development of the secondary to ACEI cough leads to discontinuation of the drugs of this group. Assessing the safety of the ACEIs with further development of customized approaches for their administration is a major scientific and practical problem. The objective of this study was to assess the association of the genetic markers with the development of the adverse drug reaction in the form of secondary to enalapril dry cough in the patients with essential arterial hypertension.

METHODS

Study involved 113 patients with the secondary to enalapril cough and 104 patients without development of the secondary to enalapril adverse drug reaction.

RESULTS

The patients carriers of the genotype AA rs2306283 of gene SLCO1B1 had 2-fold higher odds of developing the dry cough than those with the genotypes AG and GG (ОR=2.01, 95%CI=1.10-3.66, р=0.023). Similarly, the patients heterozygous for rs8176746 of gene АВО had 2.3-fold higher odds of developing the ADR in the form of dry cough than the carriers of the genotypes GG and TT (ОR=2.30, 95%CI=1.24-4.29, р=0.008).

CONCLUSIONS

Statistically significant association between the development of the ADR in the form of secondary to enalapril dry cough and polymorphisms rs2306283 of gene SLCO1B1 and rs8176746 of gene ABO was revealed.

Different Trajectories for Diabetes Mellitus Onset and Recovery According to the Centralized Aerobic-Anaerobic Energy Balance Compensation Theory

We recently reported that the restoration of cervical vertebral arterial blood flow access (measured as systolic peak (PS)) to the rhomboid fossa leads to the recovery of the HbA1c level in the case of patients with a pre-Diabetes Mellitus (pre-DM) condition. The theory of centralized aerobic-anaerobic energy balance compensation (TCAAEBC) provides a successful theoretical explanation for this observation. It considers the human body as a dissipative structure. Reported connections between arterial hypertension (AHT) and the level of HbA1c are linked through OABFRH. According to the TCAAEBC, this delivers incorrect information about blood oxygen availability to the cerebellum. The restoration of PS normalizes AHT in 5-6 weeks and HbA1c in 12-13 weeks. In the current study, we demonstrate the model which fits the obtained experimental data. According to the model, pathways of onset and recovery from pre-DM are different. The consequence of these differences is discussed. The great significance of the TCAAEBC for medical practice forces the creation of an appropriate mathematical model, but the required adjustment of the model needs experimental data which can only be obtained from an animal model(s). The essential part of this study is devoted to the analysis of the advantages and disadvantages of widely available common mammalian models for TCAAEBC cases.

Transgenerational and intergenerational effects of early childhood famine exposure in the cohort of offspring of Leningrad Siege survivors

Famine exposure during early life development can affect disease risk in late-life period, yet, transmission of phenotypic features from famine-exposed individuals to the next generations has not been well characterized. The purpose of our case-control study was to investigate the association of parental starvation in the perinatal period and the period of early childhood with the phenotypic features observed in two generations of descendants of Leningrad siege survivors. We examined 54 children and 30 grandchildren of 58 besieged Leningrad residents who suffered from starvation in early childhood and prenatal age during the Second World War. Controls from the population-based national epidemiological ESSE-RF study (n = 175) were matched on sex, age and body mass index (BMI). Phenotypes of controls and descendants (both generations, children and grandchildren separately) were compared, taking into account multiple testing. Comparison of two generations descendants with corresponding control groups revealed significantly higher creatinine and lower glomerular filtration rate (GFR), both in meta-analysis and in independent analyses. The mean values of GFR for all groups were within the normal range (GFR less than 60 mL/min/1.73 m² was recorded in 2 controls and no one in DLSS). Additionally, independent of the creatinine level, differences in the eating pattern were detected: insufficient fish and excessive red meat consumption were significantly more frequent in the children of the Leningrad siege survivors compared with controls. Blood pressure, blood lipids and glucose did not differ between the groups. Parental famine exposure in early childhood may contribute to a decrease in kidney filtration capacity and altered eating pattern in the offspring of famine-exposed individuals.

Association of Single-Nucleotide Polymorphisms Rs2779249 (chr17:26128581 C>A) and Rs rs2297518 (chr17: chr17:27769571 G>A) of the NOS2 Gene with Tension-Type Headache and Arterial Hypertension Overlap Syndrome in Eastern Siberia

Inducible nitric oxide (NO) synthase (iNOS), encoded by the NOS2 gene, promotes the generation of high levels of NO to combat harmful environmental influences in a wide range of cells. iNOS can cause adverse effects, such as falling blood pressure, if overexpressed. Thus, according to some data, this enzyme is an important precursor of arterial hypertension (AH) and tension-type headache (TTH), which are the most common multifactorial diseases in adults. The purpose of this study was to investigate the association of rs2779249 (chr17:26128581 C>A) and rs2297518 (chr17: chr17:27769571 G>A) of the NOS2 gene with TTH and AH overlap syndrome (OS) in Caucasians in Eastern Siberia. The sample size was 91 participants: the first group-30 patients with OS; the second group-30 patients AH; and the third group-31 healthy volunteers. RT-PCR was used for the determination of alleles and genotypes of the SNPs rs2779249 and rs2297518 of the NOS2 gene in all groups of participants. We showed that the frequency of allele A was significantly higher among patients with AH compared with healthy volunteers (p-value < 0.05). The frequency of the heterozygous genotype CA of rs2779249 was higher in the first group vs. the control (p-value = 0.03), and in the second group vs. the control (p-value = 0.045). The frequency of the heterozygous genotype GA of rs2297518 was higher in the first group vs. the control (p-value = 0.035), and in the second group vs. the control (p-value = 0.001). The allele A of rs2779249 was associated with OS (OR = 3.17 [95% CI: 1.31-7.67], p-value = 0.009) and AH (OR = 2.94 [95% CI: 1.21-7.15], p-value = 0.015) risks compared with the control. The minor allele A of rs2297518 was associated with OS (OR = 4.0 [95% CI: 0.96-16.61], p-value = 0.035) and AH (OR = 8.17 [95% CI: 2.03-32.79], p-value = 0.001) risks compared with the control. Therefore, our pilot study demonstrated that the SNPs rs2779249 and rs229718 of the NOS2 gene could be promising genetic biomarkers for this OS risk in Caucasians from Eastern Siberia.

Pharmacoepidemiological analysis of antihypertensive therapy in older age groups with senile asthenia syndrome

Aim. To conduct a pharmacoepidemiological study to determine the characteristics of antihypertensive therapy in older patients with senile asthenia syndrome (SSA) and compliance of this therapy with modern clinical recommendations. Materials and methods. The study included 146 patients diagnosed with stage IIII hypertension who underwent inpatient treatment in the therapeutic department of the Krasnoyarsk Regional Hospital for War Veterans, the subjects were divided into two groups. The first group included 55 elderly patients (WHO, 2012) with hypertension and SSA. The second group included 35 elderly patients (WHO, 2012) with hypertension and SSA. The comparison group consisted of 56 patients aged 60 to 84 years with hypertension without SSA. Evaluation of the pharmacotherapy was carried out based on extracts from the medical histories of inpatient patients. Results. The most commonly taken groups of antihypertensive drugs in patients of older age groups with hypertension and SSA according to the study are diuretics and -blockers. Diuretics were taken by 88.6% of elderly patients and 83.6% of senile patients. The main combinations of antihypertensive drugs in patients with hypertension and SSA were: a two-component scheme of combination of an ACE inhibitor and a diuretic, a three-component scheme of combination of an ACE inhibitor, a -blocker and a diuretic, four-component schemes of combination of an ACE inhibitor, a -blocker, a calcium channel blocker and a diuretic, as well as a combination of an angiotensin II receptor blocker, a -blocker, calcium channel blocker and diuretic with combined medications. Conclusion. The prescribed antihypertensive therapy in patients of older age groups with hypertension and SSA in most cases is represented by a combination of several drugs. Many patients take three-component antihypertensive therapy regimens. There were no statistically significant differences between patients of older age groups with hypertension and SSA, as well as patients of older age groups with hypertension without SSA. Therefore, it can be concluded that the presence of senile asthenia syndrome does not affect the tactics of treatment of hypertension and regardless of the presence or presence of SSA, patients receive the same hypotensive therapy, which contradicts existing clinical guidelines.

Risk of fatal and non-fatal cardiovascular events in men aged 25-44 in the city of Novosibirsk. Cohort study

Aim. To study the incidence and risk factors of cardiovascular events (CVEs) during an 8-year follow-up of a cohort of men aged 25-44 years (Novosibirsk).

Material and methods. The cohort study included 1415 people aged 37,33 [31,83; 41,92] years (Median, Me [interquartile range, Q25; Q75], of which 670 (47,3%) were men. Median follow-up period was 6,9 [5,8; 7,8] years. CVEs were identified using the "Registry of Acute Myocardial Infarction", fatal cases — from the "Medical Certificates of Cause of Death". The examination program included a questionnaire, anthropometry, biochemical studies. Statistical processing was carried out using SPSS (version 13.0).

Results. Thirteen CVEs were identified, of which 6 were fatal. Survival prognosis was more favorable in men without hypertension, with a heart rate (HR) <80 bpm. The risk of CVEs increased by 14% with an increase in fasting plasma glucose by 0,5 mmol/l, by 1,8 times with creatinine increase by 10 pmol/l (decreased by 29% with an increase in glomerular filtration rate by 5 ml/min /1,73 m2); 2 times with a heart rate increase by 10 bpm, regardless of other cardiometabolic risk factors.

Conclusion. Significant risk factors for fatal and non-fatal CVEs in men aged 25-44 years are hypertension, heart rate >80 bpm, increased fasting plasma glucose, creatinine levels (or decreased glomerular filtration rate).

Comparative analysis of tryptophan and downstream metabolites of the kynurenine and serotonin pathways in patients with arterial hypertension and coronary artery disease

Aim    To compare serum concentrations of tryptophane (Trp) and its metabolites in subjects with no cardiovascular disease (CVD) and patients with СVD, including arterial hypertension (AH) and ischemic heart disease (IHD).Material and methods    This study included 131 participants; 58 participants (11 of them with documented peripheral atherosclerosis) were included into the AH group, 46 participants were included into the IHD group, and 27 participants with no signs of CVD were included into the control group. Plasma concentrations of Trp and its metabolites were measured by high-performance liquid chromatography in combination with a triple quadrupole analyzer.Results    Comparison of the three study groups revealed significant differences in concentrations of Trp (р=0.029), kynurenine (p<0.001), kynurenine/Trp ratio (p<0.001), quinolinic acid (р=0.007), kynurenic acid (р=0.003), serotonin (p<0.001), and 5‑hydroxyindoleacetic acid (5‑HIAA) (р=0.011). When the AH group was subdivided into subgroups without and with documented peripheral atherosclerosis, the intergroup differences remained for concentrations of kynurenine, kynurenine/Trp ratio, quinolinic acid, kynurenic acid, serotonin, and 5‑HIAA. Also, correlations were found between concentrations of Trp metabolites and laboratory and instrumental data, primarily inflammatory markers. Conclusion    Analysis of serum concentrations of Trp and its metabolites in CVD patients showed increases in kynurenine, kynurenine/Trp ratio, quinolinic acid, kynurenic acid, and 5‑HIAA along with decreases in concentrations of Trp and serotonin in the groups of AH, AH with documented peripheral atherosclerosis, and IHD.

Outpatient management of patients after surgical operations for acute aortic dissection of type A

Acute aortic dissection of type A is still one of the most difficult diseases faced by doctors of all specialties. The current review is based on an analysis of current literature data and clinical guidelines. It covers various aspects of outpatient patient management and focuses on conservative therapy. The lack of an adequate diagnostic algorithm often leads to complications and, ultimately, death. The dynamic nature of the disease, the variability of clinical manifestations and the course of the pathological process require special attention. Both short-term and long-term survival of the patient depends on careful observation. Postoperative management of patients with acute aortic dissection of type A is entirely entrusted to the outpatient unit, which, due to the absence of the main aspects of the strategy in modern clinical recommendations, is not always prepared for the curation of this complex cohort of patients. The lack of experience in managing this pathology by outpatient hospital doctors causes significant difficulties in interpreting instrumental diagnostic methods, which leads to further erroneous tactics with the development of long-term complications. Due to the lack of a unified scheme of drug therapy, the question of prescribing drugs in these patients, who often receive a fairly large range of medications for concomitant pathology, remains open. These factors contribute to polyprogmasia or vice versa – insufficient volume of drug therapy, which further leads to the progression of the disease. As a result of insufficient emphasis on the basics of outpatient management of this cohort of patients, a whole complex of problems arises, leading to unsatisfactory treatment results and increased healthcare costs for their subsequent solution. The purpose of the review is to highlight the main problems of this issue from the point of view of evidence-based medicine.

Physicians’ knowledge and preferences in tactics of management and rational pharmacotherapy of arterial hypertension in pregnant women (PHYGEST study)

Introduction: The issues of rational antihypertensive therapy in pregnant women are always extremely relevant, since high blood pressure in a pregnant woman is associated with serious risks for a mother and a fetus.

The aim of the study: To determine the knowledge and preferences of physicians in the management of pregnant women with arterial hypertension.

Materials and methods: A multicenter study was conducted in 2018–2021 using an anonymous questionnaire among 411 doctors from 8 regions of Russia.

Results and discussion: The levels of knowledge and preferences of specialists in the issues of diagnosing and formulating a diagnosis of arterial hypertension and preeclampsia in pregnant women, prescribing basic and additional drugs for the treatment and prevention of hypertension were revealed, and the degree of compliance with the current clinical guidelines was assessed.

Conclusion: Due to the insufficient level of knowledge of specialists, it is required to pay increased and special attention to this problem, strengthen control over compliance with clinical guidelines, and introduce it into postgraduate recommendations and continuing education programs.

Is high normotension a norm or a risk factor for perinatal complications: prospective cohort study

Aim. Comparative assessment of the effect of high normotension and hypertension 12nd stage on the risk of gestational and perinatal complications. Materials and methods. A prospective cohort study (n=110) assessing the effect of high normotension on the risk of gestational complications and pregnancy outcomes was conducted. The main group (n=70) included 30 patients with high normotension subgroup A, and 40 patients with hypertension 12nd stage subgroup B. The comparison group included 40 patients with "white coat hypertension". Results. The most frequent complications in the 2nd and 3rd trimesters of pregnancy were toxaemia, threatened miscarriage, edema (detected in more than half of patients with high normotension and hypertension 12nd stage) and well as threatened preterm labor (p0.05). The frequency of pre-eclampsia development in subgroups A and B did not differ significantly, however, in patients with high normotension in the 3rd trimester during a test of endothelium-dependent vasodilation were detected signs of endothelial dysfunction, which may be one of the mechanisms for the subsequent formation of hypertension in these patients. Placental insufficiency of varying severity was detected only in subgroups A and B. Placental insufficiency, along with intrauterine fetal hypoxia of different etiologies, were the most frequent causes of emergency caesarean section, occurring only in the main group 3 (75.0%) in subgroup A and 6 (66.67%) in subgroup B and associated with blood pressure above 130/85 mm Hg. Conclusion. The importance of preventing blood pressure increase to high normal rate is explained by the development of endothelial dysfunction at late gestation, which can serve as the mechanisms of hypertension formation in this category of pregnant women.

Comparative Pharmacoepidemiological Assessment of Antihypertensive Drugs Administration Structure in Pregnant Women in Routine Medical Practice in Kursk and Chisinau

Aim. To study the structure of antihypertensive drugs prescription in pregnant women in routine practice in Kursk and Chisinau.Material and methods. The study design was observational descriptive cross-sectional. Authors conducted a survey of doctors in medical organizations in Kursk and Chisinau in 2017-2018.Results. Respondents from Kursk and Chisinau preferred methyldopa in prescriptions of central alpha-adrenergic receptor agonists. Doctors from Chisinau used clonidine in 14.3% of cases. The leading place in the group of calcium channel blockers belonged to short-acting nifedipine. Among beta-blockers in Kursk, doctors most often prescribed bisoprolol (43.3%), metoprolol (21.7%) and nebivolol (13.3%), while in Chisinau the preference was given to metoprolol (32.1%), atenolol (19.6%) and bisoprolol (16.1%). From the group of diuretics, Kursk doctors mainly prescribed hydrochlorothiazide (10%), indapamide (6.7%); in Chisinau, indapamide was the leader (19.6%), hydrochlorothiazide was used less frequently (7,1%). From the class of alpha-blockers, prazosin occupied the leading position among respondents in Kursk, and terazosin in Chisinau.Conclusion. The priority drug classes in both regions were calcium channel blockers, central alpha-adrenergic receptor agonists and beta-blockers. A small number of not recommended drugs prescriptions have been registered. In general, the prescribed treatment corresponded to the current guidelines and protocols for the management of patients with arterial hypertension during pregnancy.

Content of matrix metalloproteinases in the blood of hypertensive patients with a high cardiovascular risk receiving statin therapy

Aim. To compare the effect of atorvastatin and rosuvastatin as part of complex therapy in patients with hypertension (HTN) with a high cardiovascular risk on the level of matrix metalloproteinases -1, -9 (MMP-1, MMP-9) and tissue inhibitors of metalloproteinases -1, -4 (TIMP-1, TIMP-4).

Material and methods. The study included 140 hypertensive patients who received atorvastatin (Liprimar) 20 mg/day in addition to antihypertensive therapy for a year, which was later replaced by rosuvastatin (Rosucard) in the following doses: 10 mg/day (n=96), 20 mg/day (n=24), 40 mg/day (n=26). Patients underwent standard clinical and paraclinical investigations. In the blood serum of patients, the levels of MMP-1, MMP-9 and TIMP-1, TIMP-4 were determined.

Results. Patients who used rosuvastatin at a dose of 40 mg/day had a more pronounced decrease in MMP-1 than those treated with rosuvastatin at a dose of 10 and 20 mg/day (p<0,05), while there were no differences in MMP-1 when using low and medium doses. Rosuvastatin had a less pronounced effect on MMP-9 than on MMP-1, while increasing the dose of rosuvastatin did not affect the intensity of MMP-9 reduction (p>0,05). The content of TIMP-1 and TIMP-4 increased when taking rosuvastatin, while a more pronounced dose-dependent increase in TIMP-1 was observed with rosuvastatin 20 mg/day and 40 mg/day. In addition, the largest increase in TIMP-4 was observed when using rosuvastatin at a dose of 40 mg/day. Atorvastatin had no significant effect on MMP-1 and MMP-9, as well as TIMP-1 and TIMP-4.

Conclusion. Long-term rosuvastatin therapy (10 mg/day, 20 mg/day, 40 mg/day) as part of the complex therapy of cardiovascular patients affects the metabolism of vascular wall elastin and collagen, reducing the level of MMP-1, MMP-9 and increasing the content of TIMP-1, TIMP-4 in the blood.

Pararenalfat Tissue: Rate of Pararenal Obesity and Relation with Anthropometric Indices of Obesity

Aim. To study a rate of excessive pararenal fat tissue (PRFT) thickness and its relationship with anthropometric obesity indices.Material and methods. 372 patients (152 men and 220 women) were included in the study, the average age was 63.5±13.3 years. There were measured: height, weight, waist circumference (WC), hip circumference (HC), body mass index (BMI), WC/height ratio, sagittal abdominal diameter (SAD), body fat percentage (BFP), body surface area (BSA), body adiposity index (BAI) and visceral obesity index (VAI). All subjects underwent abdominal multispiral computed tomography. PRFT thickness was detected on a single slice at the level of the left renal vein.Results. 27% of the examined group had BMI<25 kg/m2, 28% – excessive body mass, 45% – obesity. The median PRFT thickness was 1.61 (1.03; 2.46) cm. There were correlations between PRFT thickness and glucose (r=0,64, p<0,05) and uric acid (r=0,46, p<0,05) levels. The threshold of referential PRFT thickness was 1,91cm. The rate of pararenal obesity was 9,9% among those with normal body mass, 29,3% in excessive body mass, 66,1% – in 1 class obesity, 67,7% – in 2 class, and 90,1% – in 3 class. The correlation analysis revealed a significant positive correlation between the PRFT thickness and obesity indices with exception of VAI and BAI: with BMI (r=0.43, p<0.05), WC (r=0.57, p<0.05), SAD (r=0.58, p<0.05), BFP (r=0.48, p<0.05), WC/height ratio (r=0.46, p<0.05), and BSA (r=0.58, p<0.05).Conclusion. Excessive PRFT may be detected isolated without any external anthropometric signs of obesity, wherein it is an active component of metabolic disorders typical for obesity. The most significant indices for the detection of pararenal obesity may be WC, SAD, and BSA.

[Ectopic obesity in patients without manifested cardiovascular disease: regulations, frequency and clinical characteristics]

AIM

To determine the frequency, distribution and characteristics of ectopic obesity in patients without manifested cardiovascular disease.

MATERIALS AND METHODS

We examined 320 patients without manifested cardiovascular disease (average age 63.813.9 years), 38 of them without cardiovascular risk factors (healthy referent group). Anthropometric indicators were measured, body mass index (BMI) was calculated. Degree, type of obesity, lipid profile were evaluated. All patients underwent multi-detector chest computed tomography in spiral mode on Toshiba Aquilion Prime scanner using standardized protocol. Perivascular adipose tissue (PVAT) and pericardial adipose tissue (PAT) were detected using specialized semi-automatic software Tissue Composition Module QCTPro (Mindways Software, Inc., USA) after scanner calibration with special phantom. PAT and PVAT exceeding the 90th percentile in the healthy referent group were considered as ectopic obesity. Statistical analysis was performed using Statistica 10.0 software (StatSoft Inc., USA).

RESULTS

PAT volume 3.2 cm3 and PVAT volume 0.4 cm3 were criteria for high pericardial and high perivascular fat; 81 (25.2%) patients had ectopic obesity, 85 (26.5%) patients abdominal obesity; 146 (42.9%) people had high pericardial fat, 134 (39.4%) high perivascular fat. The frequency of ectopic obesity in patients with arterial hypertension (AH) was statistically significantly higher compared to persons without AH. Significantly more often ectopic forms of obesity were detected in patients with overweight and obesity. The high pericardial fat and high perivascular fat were found in patients with overweight and normal body weight. When comparing the clinical characteristics of patients with abdominal and ectopic obesity, metabolic parameters, as well as the incidence of hypertension and dyslipidemia, did not differ significantly.

CONCLUSION

Ectopic obesity can develop outside of global obesity. In addition, this type of obesity is accompanied by metabolic disorders and AH, regardless of the abdominal distribution of adipose tissue.

New Genetic Biomarkers of the Overlap Syndrome Tension-Type Headache and Arterial Hypertension

BACKGROUND

Nitric oxide (NO) is an important autocrine and paracrine signaling molecule that plays a crucial role in cardiovascular physiology and pathology regulation. NO is an important molecule involved in regulation of cerebral and extra cerebral cranial blood flow and arterial diameters. Reduced bioavailability of NO in the endothelium is an important precursor for impaired vasodilation and arterial hypertension (AH). Furthermore, NO is involved in nociceptive processing. A NO-induced biphasic response with immediate and a delayed headache is typical for chronic tension-type headaches (TTH) in humans. The aim was to study the association of allelic variants and genotypes of the single nucleotide variant (SNV) rs3782218 of the NOS1 gene with the TTH and AH overlap syndrome development in middle age adults.

MATERIALS AND METHODS

We observed 91 Caucasian participants who resided in Krasnoyarsk city: group 1 (TTH and AH overlap syndrome)-30 patients; group 2 (AH without headache)-30 patients; group 3 (control)-31 healthy volunteers. The diagnosis of AH was based on criteria of the European Society of Cardiology and the European Society of Hypertension (2018) и criteria of the Russian Society of Cardiology (2020). Diagnosis of TTH was based on criteria of the International Classification of Headache Disorders (2018). Real-time polymerase chain reaction was used for the determination of allelic variants and genotypes of the SNV rs3782218 of the NOS1 gene in all groups of participants.

RESULTS

The frequency of the minor allele T of rs3782218 was statistically significantly higher by 16.7 times in group 1 (TTH and AH) compared to group 3 (control): 26.7% versus 1.6%, respectively (p-value = 0.000065) and 3.2 times higher in group 1 (TTH and AH) compared to group 2 (AH without headache): 26.7% versus 8.3%, respectively (p-value = 0.008). The frequency of the heterozygous (CT) genotype was statistically significantly higher in group 1 (TTH and AH) compared to group 3 (control): 40.0% versus 3.2% (p-value = 0.000454) and in group 1 (TTH and AH) compared to group 2 (AH without headache): 40.0% versus 16.7% (p-value = 0.045). The minor allele T was statistically significantly associated with a high risk of developing the TTH and AH overlap syndrome compared with the controls (odds ratio (OR) = 22.2 (95% confidential interval (CI): 2.8-173.5)) and compared with AH without headache (OR = 4.0 (95% CI: 1.4-11.8)). Although the frequency of the minor allele T was 5.2 times higher in group 2 (AH without headache) compared with group 3 (control), there were not statistically significantly differences (p-value = 0.086).

CONCLUSION

Thus, the minor allele T of rs3782218 of the NOS1 gene is an important genetic biomarker for a high risk of developing the TTH and AH overlap syndrome in hypertensive patients.

Arterial hypertension as a consequence of endothelial glycocalyx dysfunction: a modern view of the problem of cardiovascular diseases

Arterial hypertension (AH) is a leading risk factor for the development of cardiovascular, cerebrovascular, and renal diseases, which are among the top 10 most common causes of death in the world. The etiology of hypertension has not been fully elucidated, but it has been established that endothelial dysfunction is the most significant pathogenetic link in the formation and progression of the disease. The data obtained in the last 10-15 years on endothelial glycocalyx (eGC) studies indicate that endothelial dysfunction is preceded 

by destabilization and shedding of eGC with the appearance of its soluble components in the blood, which is equivalent to a process that can be designated as eGC dysfunction. Signs of eGC dysfunction are expressed in the development of hypertension, diseases of the cardiovascular system, and their complications. The purpose of this review is to analyze and substantiate the pathophysiological role of eGC dysfunction in hypertension and cardiovascular diseases and to describe approaches for its assessment and pharmacological correction. Abstracts and full-size articles of 425 publications in Pubmed/MEDLINE databases over 20 years were studied. The review discusses the role of eGC in the regulation of vascular tone, endothelial barrier function, and anti-adhesive properties of eGC. Modifications of eGC under the influence of pro-inflammatory stimuli, changes in eGC with age, and with increased salt load are considered. The aspect associated with eGC dysfunction in atherosclerosis, hyperglycemia and hypertension is covered. Assessment of eGC dysfunction is difficult but can be performed by indirect methods, in particular by detecting eGC components in blood. A brief description of the main approaches to pharmacoprevention and pharmacocorrection of hypertension is given from the position of exposure effects on eGC, which currently has more a fundamental than practical orientation. This opens up great opportunities for clinical studies of eGC dysfunction for the prevention and treatment of hypertension and justifies a new direction in the clinical pharmacology of antihypertensive drugs.

Uric Acid as a Risk Factor for Cardiovascular Diseases

Recently, hyperuricemia and its association with cardiovascular disease have been receiving more and more attention. The article talks about the role of uric acid in the body, the reasons for its increase and the impact of elevated uric acid levels on the cardiovascular system. The mechanisms of influence of hyperuricemia on the development and progression of cardiovascular diseases are presented. Medicinal and non-drug ways to reduce the level of uric acid in the blood are considered. From non-drug methods, attention is focused on the hypopurine diet, adequate drinking regimen and normalization of body weight. Separately, the effect on the level of uric acid of various drugs used in clinical practice is considered. In the light of current clinical guidelines, the issue of the need to prescribe drug therapy for asymptomatic hyperuricemia is discussed.

Detection and Treatment of Hyperuricemia in Clinical Practice (According to the PROFILE Outpatient Registry)

Aim. To study the frequency of detection of hyperuricemia (HU) in patients with high and very high cardiovascular risk and the frequency of prescribing drugs that lower serum uric acid (sUA) levels in real clinical practice.

Material and methods: The general information of the study was based on the data of 2457 patients who were consistently included in the «PROFILE» registry until November 30, 2020: 1250 men (50.9%) and 1207 (49.1%) women. All patients with HU were selected (UA level ≥360 pmol/l in women, ≥420 pmol/l in men). At the stage of inclusion of the patient, data on MC indicators were available in 1777 (72.3%), upon re-examination - only 262 (33.2%) out of 790 patients who returned to the appointment.

Results: The most common study of the level of sUA was performed in patients with gout (65.2%), with arterial hypertension (AH) and dyslipemia in 29.1% of cases, with diabetes mellitus (DM) - 30.1%, with impaired tolerance to glucose (IGT) - 40.2%, with other diseases, the proportion of patients with a known UA was even less. A positive relationship was found between the presence of AH and IGT with the frequency of UA control (p<0.001). In patients with AH, an increase in the level of sUA was detected significantly more often than in patients without AH (p<0.001), and less frequently in patients with DM and IGT (p<0.001 and p<0.01, respectively). The frequency of allopurinol prescribing was low: 49 (2%) patients received therapy, while of the 284 patients with HU, only 20 (7%) were prescribed allopurinol.

Conclusion: in real clinical practice, only 29.1% of patients with AH and 20-25% of patients with other CVDs were monitored for sUA levels, every third patient had data on sUA levels at a repeat visit. In the presence of gout, the proportion of patients with current UA was higher (65%). For those with AH and IGT, positive correlations were found between the presence of the disease and control of sUA levels. A low frequency of prescribing drugs for the correction of HU was revealed.

Parameters of the Infrastructure of the Residential Area and Their Relationship with Cardiovascular Risk Factors

Aim. This study determined the level of public satisfaction with neighborhood design features in Kemerovo Oblast and their connection to cardiovascular disease risk factors.

Subjects and methods. The study population included 1,598 respondents aged between 35 and 70, with 491 living in rural areas and others living in Kemerovo (1,221 women and 477 men). The assessment of neighborhood environment was done according to residents' subjective opinions about infrastructural features (the Neighborhood Environmental Walkability Scale). Depending on how participants responded to the questionnaire, some of these parameters were identified as adverse.

Results. The residents of Kemerovo and rural areas of Kemerovo Oblast identified the following neighborhood design features as adverse: the lack of interesting places in neighborhood environment, the remote location of parks and restaurants, the absence of pavement, busy traffic, and a long distance between home and workplace. In the city, arterial hypertension prevalence was high among men, when grocery, fruit and clothing stores were distant, and among women, when banks, public transport stops were distant and the traffic was heavy. Lipid metabolism disorders were more common among women in urban areas, when there were no interesting places around. Obesity prevalence was high among urban female population, when the following adverse factors were present: the remote location of grocery stores, fruit stores, bank, pharmacy and public transport stops and the absence of pavement. Among rural male population, this risk factor was common when there were no pavements. The highest rate of carbohydrate metabolism disorders was found among women living in villages where the traffic is heavy and public transport stops are far away.

Conclusion. The impact of infrastructure on the health status of the living population is a new direction of scientific research. Epidemiological studies in different geographic areas and population groups show significant differences in health status, morbidity and mortality from chronic noncommunicable diseases. To reduce the risks of developing diseases of the cardiovascular system, the formation of a socially comfortable health-saving environment is of great importance.

Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction In Patients With Resistant Hypertension and Type 2 Diabetes Mellitus

Aim      To study the incidence and clinical and pathophysiological features of diastolic dysfunction (DD) and chronic heart failure with preserved ejection fraction (HFpEF) in patients with resistant arterial hypertension (RAH) associated with type 2 diabetes mellitus (DM).Material and methods  A cross-sectional study that included 36 patients with RAH associated with type 2 DM (mean age, 61.4±6.4 years; 14 men) was performed. Measurement of office and 24-h blood pressure (BP), standard echocardiography with assessment of diastolic function (DF) and ventricular-arterial coupling, doppler ultrasound imaging of renal blood flow, and laboratory tests (blood glucose, glycated hemoglobin, blood creatinine, tumor necrosis factor α (TNF-α), brain natriuretic peptide (BNP), type 2 and type 9 matrix metalloproteinases (MMP-2 and MMP-9), tissue inhibitor of MMP 1 (TIMP-1), 24-h urine protein test, and 24-h urine volume test were performed for all patients. HFpEF was diagnosed according to criteria of the American Society of Echocardiography and the European Society of Cardiology 2019, and the Russian Clinical Guidelines on Diagnosis and Treatment of CHF 2017 and 2020.Results All patients had DD. Incidence of HFpEF detection according to the Russian Guidelines 2017 was 100%; according to the Russian Guidelines 2020, that included a required increase in BNP, and according to the criteria of the European Guidelines 2019, this incidence was 89 %. In 55.6 % of patients, DD corresponded to grade 2 (pseudonormal type). According to the correlation analysis, the DF impairment was associated with increases in pulse BP, myocardial mass, arterial and left ventricular elastance (arterial wall and left ventricular elasticity), basal glycemia and DM duration, MMP-2 level, proteinuria, blood creatinine, renal vascular resistance, and also with decreases in 24-h urine volume, MMP-9, TIMP-1, and TIMP-1/MMP-2. Significance of the relations of mean E / e' ratio with nighttime pulse BP, MMP-9, and 24-h urine volume were confirmed by results of multiple linear regression analysis. Increased myocardial and vascular wall stiffness, concentrations of MMP-2 and TNF-α and reduced 24-h urine volume were associated with progressive impairment of DF.Conclusion      The combination of RAH and DM-2 is characterized by an extremely high incidence of DD that determines a great prevalence of HFpEF. The development and progression of DD in such patients are closely related with a complex of metabolic, proinflammatory and profibrotic biomarkers, increased vascular wall stiffness, pronounced left ventricular hypertrophy, and with structural and functional alterations in kidneys.

Office blood pressure: overcoming the problems of diagnosis and control of arterial hypertension treatment

Some national guidelines since 2017 considered the most common method for diagnosing and controlling hypertension (HTN) (office blood pressure (OBP) measurement) as screening only. Automated OBP (AOBP) measurement claims to be a unique method by obtaining a standardized result, even in primary health care. AOBP improves the reliability of data by reducing the influence of various errors on result. However, although the level of AOBP is on average lower than similar OBP in clinical and research practice and is comparable to the mean 24-hour BP monitoring, at present, all international guidelines emphasize the mandatory use of ambulatory BP measurements for diagnostic purposes. Whether the results of AOBP and the reference level ≥130/80 mm Hg are equivalent with the same OBP level, the use of which is associated with an increase in the prevalence of hypertension and insufficient control of antihypertensive therapy, is a question for research. Compared with conventional OBP, the use of AOBP in conjunction with outpatient measurement leads to a reduction in the proportion and timing of initiation of treatment in patients with masked HTN, whose cardiovascular risk is similar to that of patients with stable HTN. However, the widespread implementation of AOBP is hindered by the high cost and lack of accumulated data. The review analyzes in detail the limitations and advantages of various types of BP measurement, as well as the potential of using AOBP in modern clinical and research practice.

 

High normal blood pressure and left ventricular structural and functional disorders in young adults

Aim. To evaluate the association of a high normal blood pressure (BP) with the risk of early hypertension-mediated organ damage (HMOD) in young adults.

Material and methods. Medical screening of population aged 18-45 years (n=987) revealed that in 173 persons, office BP corresponded to a high normal level or hypertension (HTN). Echocardiography (GE Healthcare Vivid 9, using EchoPAC Software) was performed when HTN was confirmed by office BP measurement and/or according to 24-hour ambulatory BP monitoring (ABPM) (n=127). In addition, creatinine and albumin-to-creatinine ratio in spot urine were measured.

Results. The median age was 23 [21; 25] years. The median systolic (SBP) and diastolic BP (DBP) was 129 [121; 137] and 75±12 mm Hg, respectively. The detection rate of LV geometry abnormalities was 3,3 times higher in the high normal BP group [95% CI, 1,06-6,28, p=0,02], and 10,7 times higher in the HTN group [95% CI, 2,32-16,49, p=0,04] compared with the optimal+normal BP group. In a multivariate analysis, the independence of associations with the LV mass index (LVMI) was confirmed only for the mean nighttime DBP, left atrial volume index, and the ratio of LV peak early diastolic velocity to the average septal and lateral peak early diastolic mitral annular velocity.

Conclusion. In young people, the prevalance of HMOD is comparable in the groups with high normal BP and HTN, while significant differences were found between the group with optimal+normal BP levels and patients with HTN and high normal BP. An independent association of elevated LVMI with mean nighttime DBP was found.

Prognostic value of hypoxia-inducible factor-1 alpha gene polymorphism in patients with heart failure with preserved ejection fraction and obstructive sleep apnea

Aim. To study the associations of hypoxia-inducible factor-1 alpha (HIF-1α) gene polymorphism (rs11549465) with the clinical course of heart failure (HF) with reserved ejection fraction (HFpEF) in patients with obesity and moderate and severe obstructive sleep apnea (OSA).

Material and methods. The study included 76 men with HFpEF and OSAS. Patients underwent a polysomnography, echocardiography, and a 6-minute walk test. In addition, apnea/hypopnea index was calculated, and the level of N-terminal pro-brain natriuretic peptide (NT-proBNP) was assessed. HIF1A gene polymorphisms (rs11549465) were analyzed using polymerase chain reaction. After 12-month follow-up, the clinical course of HF was assessed.

Results. The T/T genotype of the HIF1A gene was associated with a high risk of HF progression (p=0,004), development of supraventricular premature beats (p=0,004) and atrial fibrillation (p=0,039). Carrying the T/T genotype was associated with severe OSA (p=0,006) and increased NT-proBNP (p=0,044), and also correlated with certain echocardiographic characteristics of myocardial remodeling.

Conclusion. T/T genotype of the HIF1A gene is associated with OSA severity and increased NT-proBNP, as well as with the severity of left and right heart remodeling. The carriage of this genotype was associated with an unfavorable course of HF and an increased risk of atrial fibrillation in patients with HFpEF and OSA.

Effective drug modification of risk factors in a patient with coronary artery disease: a case report

The basis of conservative treatment of stable coronary artery disease is the elimination of modifiable risk factors and complex drug therapy for hypertension, diabetes, and dyslipidemia. The rates of awareness, treatment and control of these parameters in Russia remain low. In this regard, current guidelines suggest a step-by-step personalized approach to achieve optimal risk factor control. The aim of this work was to demonstrate that the modification of therapy to achieve the targets of blood pressure, low-density lipoprotein cholesterol and glycated hemoglobin, lifestyle change with smoking cessation, increased physical activity and weight loss led to improvement of coronary circulation and elimination of angina episodes.

[Correlations between vessel stiffness and biomarkers of senescent cell in elderly patients]

Aim    To study the association between vascular wall stiffness and known markers for accumulation of senescent cells in blood, cells, and tissues of old patients.Material and methods    This study included male and female patients aged 65 years and older who were referred to an elective surgical intervention, that included a surgical incision in the area of the anterior abdominal wall or large joints and met the inclusion and exclusion criteria. For all patients, traditional cardiovascular (CV) risk factors and arterial wall stiffness (pulse wave velocity, PWV) were evaluated. Also, biomaterials (peripheral blood, skin, subcutaneous adipose tissue) were collected during the surgery and were used for isolation of several cell types and subsequent histological analysis to determine various markers of senescent cells.Results    The study included 80 patients aged 65 to 90 years. The correlation analysis identified the most significant indexes that reflected the accumulation of senescent cells at the systemic, tissue, and cellular levels (r&gt;0.3, р&lt;0.05) and showed positive and negative correlations with PWV. The following blood plasma factors were selected as the markers of ageing: insulin-like growth factor 1 (IGF-1), fibroblast growth factor 21 (FGF-21), and vascular endothelium adhesion molecule 1 (VCAM-1). A significant negative correlation between PWV and IGF-1 concentration was found. Among the tissue markers, P16INK, the key marker for tissue accumulation of senescent cells, predictably showed a positive correlation (r=0.394, p&lt;0.05). A medium-strength correlation with parameters of the 96-h increment of mesenchymal stromal cells and fibroblasts and a weak correlation with IL-6 as a SASP (specific senescent-associated secretory phenotype) were noted. Results of the multifactorial linear regression analysis showed that the blood plasma marker, VCAM-1, and the cell marker, 96-h increment of fibroblasts, were associated with PWV regardless of the patient's age.Conclusion    Stiffness of great arteries as measured by PWV significantly correlates with a number of plasma, tissue, and cellular markers for accumulation of senescent cells. This fact suggests PWV as a candidate for inclusion in the panel of parameters for evaluation and monitoring of the biological age during the senolytic therapy.

[Pharmacotherapy optimization opportunities using fixed combinations in patients with high cardiovascular risk]

This review focuses on the role of arterial hypertension and hyperlipidemia as the most important risk factors of early disability and death. The facts are provided that many persons with those risk factors do not have the adequate control of blood pressure and atherogenic fractions of blood serum lipoproteins. The review addresses prospects for optimizing pharmacotherapy with fixed combinations of drugs for arterial hypertension and dyslipidemia. From the perspective of effective clinical guidelines and the available evidence base, the authors reviewed possibilities for improving the treatment compliance by using combinations of antihypertensive and hypolipidemic drugs in a single dosage form. Implementation of such complex, optimized treatment using a three-component fixed-dose combination is considered.

Comparative efficacy of ivabradine and beta-blockers in the treatment of tachycardia in patients after COVID-19

Aim. To assess the changes of heart rate (HR), exercise tolerance and quality of life in patients after coronavirus disease 2019 (COVID-19) during treatment with ivabradine monotherapy or in combination with beta-blockers (BB) compared with BB monotherapy.

Material and methods. This randomized comparative study included 90 patients discharged from a university hospital after an acute COVID-19. The main group (n=60) received, in addition to standard therapy, ivabradine monotherapy or in combination with BB, while the control one (n=30) — standard therapy in combination with BB. The follow-up period lasted 24 weeks. Statistical processing was performed using the STATISTICA 8.0 program. The level of statistical significance was p<0,05.

Results. There was a significant decrease in heart rate, an increase in physical activity, as well as an improvement in the quality of life in both groups. In the ivabradine group, significantly lower heart rates (71,2±4,1 vs 73,9±5,1 bpm (p=0,015)), significantly higher increase in physical activity (80 (60; 135) vs 65 m (40; 100) (p=0,017)) and quality of life (35 (27; 45) vs 30 (26; 36) points (p=0,03)) was revealed.

Conclusion. It has been shown that ivabradine and beta-blockers can be used in post-COVID-19 tachycardia. Ivabradine monotherapy or in combination with beta-blockers causes a more pronounced decrease in heart rate compared to beta-blocker monotherapy, accompanied by a significant improvement in exercise tolerance and quality of life in this category of patients.

[Clinical case: early connection of valsartan/sacubitril in the treatment of hypertension]

Metabolic syndrome is a disease the World Health Organization has called a new pandemic of the 21st century. Arterial hypertension is one of the criteria for this diagnosis and a determinant of damage to major target organs. The present clinical case demonstrates an experience of treatment of arterial hypertension associated with metabolic syndrome with a valsartan/sacubitril molecular complex.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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