Vol 17, No 4 (2020)

Articles
Russian medical society on arterial hypertension (RMSAH) Consensus of Experts on the use of radiofrequency denervation of the renal arteries in patients with arterial hypertension
Danilov N.M., Agaeva R.A., Matchin Y.G., Grigin V.A., Shchelkova G.V., Ripp T.M., Pekarskii S.E., Baev A.E., Chazova I.Е.
Abstract

Hyperactivity of the sympathetic nervous system is one of the basic mechanisms in the development of arterial hypertension (AH). Transcatheter renal artery denervation is aimed to destroy the renal sympathetic afferent and efferent nerves to achieve a sustained reduction in blood pressure. Since 2017, all II generation studies have demonstrated that sympathetic denervation provides clinically significant BP reduction. Russian Medical Society for Arterial Hypertension (RMSAH) experts consider SD as a possible addition to the antihypertensive strategy in patients with uncontrolled AH and recommend denervation of the renal arteries in registers and clinical trials. On the basis of existing randomized clinical trials, as well as the experience of radiofrequency denervation in Russia, the experts of RMSAH present a consensus and view of the current situation in the field of renal denervation.

Systemic Hypertension. 2020;17(4):7-18
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Primary hyperaldosteronism as a possible cause of resistant arterial hypertension
Chikhladze N.M.
Abstract

The review examines the prevalence of resistant arterial hypertension in low-renin forms of hyperaldosteronism. Possible reasons for existing differences in data on the prevalence of a heterogeneous group of primary hyperaldosteronism in the resistant course of hypertension are analyzed. Categories of patients at high risk of primary hyperaldosteronism depending on the severity of hypertension are considered. Based on the results of research, including our own data, it is shown that in most cases, tumor and hyperplastic forms of primary hyperaldosteronism are associated with severe and resistant hypertension, and the importance of diagnostic screening in this category of patients is justified.

Systemic Hypertension. 2020;17(4):20-23
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Gender-age peculiarities of smoking and diabetes mellitus role in the development of myocardial infarction in patients with arterial hypertension
Aksenova A.V., Oshchepkova E.V., Orlovsky A.A., Chazova I.E.
Abstract

Arterial hypertension (AH), smoking and type 2 diabetes mellitus (T2DM) are the risk factors for the development of myocardial infarction (MI). Their age and gender peculiarities of AH have been studied only in a small number of epidemiological studies.

Aim. To study the effect of smoking status and type 2 diabetes on the incidence of MI in men and women with hypertension.

Materials and methods. The frequency of MI in men and women with hypertension confirmed by ECG criteria was analyzed depending on age, smoking status and type 2 diabetes. 28 899 hypertensive patients of primary health care in 2010–2016 were included in the registry of hypertension.

Results. In the age of 25–44 the number of visits of men and women with hypertension in primary health care was the same, thereafter the ratio of men progressively had been decreasing with the age. The incidence of MI in men with hypertension is significantly higher at all ages than in women (it is 18.3 times higher at the age of 25–44). 37.4% of men and 94.8% of women with hypertension have never smoked. The maximum incidence of MI is in middle-aged men (33.0%) and in old-aged women (14.1%) groups, who stopped smoking. MI developed in 3.7 times more often in hypertensive young-age men group who are smoking than in nonsmokers, in those who stopped smoking – 13 times more often. The maxima of the curves of the incidence of MI in women with hypertension, based on the smoking status, shifted towards an older age in comparison with men. Percutaneous coronary intervention / Coronary artery bypass graft surgery was performed 2 times more often in hypertensive patients with MI who stopped smoking, compared to nonsmokers. The incidence of MI in hypertensive patients with diabetes in middle-aged men increased by 1.6 times, in women – 2.5 times. The higher influence of diabetes mellitus on escalation of MI incidence in women with hypertension than in men persisted until old age. The incidence of MI was 9.8% in never-smoked, 17.7% for smokers and 28.3% for stopped smoking hypertensive patients with diabetes. In the group of patients who never smoked, the risk of MI increased by 1.8 times in the men group and 2.8 in women with AH and DM. However, the odds of MI development in nonsmoking men and women groups with hypertension and diabetes did not significant.

Conclusion. Gender-age characteristics of the influence of smoking and type 2 diabetes on the risk of MI in patients with hypertension in primary health care were disclosed. Such risk factors for MI as male gender and smoking are most significant at a young age. In old age, smoking status no longer affects the risk of MI, while the male gender remains important at all ages. The higher incidence of MI in men with hypertension (18.3 times at a young age) compared to women is explained by both the influence of gender and the higher frequency of smoking (12 times). T2DM increases the risk of developing MI in middle age and older. In hypertensive patients with type 2 diabetes, the incidence of MI is maximally increased in middle age in women by 2.5 times; in men – 1.6 times. Smoking in patients with AH and type 2 diabetes leads to an additional increase of MI risk (up to 2.8 times).

Systemic Hypertension. 2020;17(4):24-31
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Contrast-associated acute kidney injury in patients with arterial hypertension and coronary artery disease and its long-term prognosis
Mironova O.I., Fomin V.V.
Abstract

Background. Arterial hypertension (AH) is frequently associated with coronary artery disease (CAD), especially in older patients and patients with comorbidities. Kidneys eliminate the contrast media after percutaneous coronary interventions and are considered target organs of AH, what makes the research of contrast-associated acute kidney injury (CA-AKI) and its long-term prognosis important topics for the researchers nowadays.

Aim. To assess the incidence of CA-AKI in patients with CAD and AH and its prognostic significance.

Materials and methods. 435 patients with stable CAD and AH and indications for studies with intraarterial iodine contrast media administration were included in the prospective open observational cohort study (ClinicalTrials.gov ID NCT04014153) with a follow-up period more than 5 years. CI-AKI was defined as the 25% rise (or 0.5 mg/dl) of serum creatinine from baseline assessed 48 hours after administration of contrast media. The primary endpoint was CI-AKI according to KDIGO criteria. The secondary endpoints were total mortality, cardiovascular mortality, myocardial infarction, stroke, acute decompensation of heart failure, coronary artery bypass grafting, repeat percutaneous coronary intervention.

Results. Most of the patients, included in the study, were overweight (BMI 29.1±4.8 kg/m2) males. 88 (20.2%) patients suffered from diabetes mellitus and 3.9% had heart failure. The mean volume of contrast media administered was 236.6±90.2 ml. The rate of CA-AKI was 82 (18.9%) cases. The cardiovascular mortality rate was 3.9%, myocardial infarction – 9.4%, stroke – 2.5%, acute decompensation of heart failure – 9.7%.

Conclusion. The rate of CA-AKI in patients with stable CAD and AH is slightly higher than in patients without such a combination of diseases. There is a trend towards better survival free of myocardial infarction, stroke or acute decompensation of heart failure in patients without CA-AKI.

Systemic Hypertension. 2020;17(4):32-36
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PAP-therapy adherence in patients with obstructive sleep apnea and cardiovascular diseases
Mikhailova O.O., Elfimova E.M., Litvin A.Y., Chazova I.E.
Abstract

Materials and methods. The study included 119 patients with obstructive sleep apnea (OSA) and cardiovascular diseases (CVD) who were followed up at the National Medical Research Center of Cardiology of the Ministry of Health of the Russian Federation in the period from 2012 to 2020, and have been receiving positive airway pressure (PAP) therapy (93 men, 78.2%). The median follow-up was 3.0 years [1.5; 5.0]. The adherence criteria were the following: the usage of the PAP device for at least 71% of nights a year, and at least 4 hours per night.

Results. 64.3% of patients met the criteria for adherence to PAP therapy (use more than 4 hours/night, more than 71% of nights). The adherent patients were older (64.0 years [58.5; 68.0] versus 59.0 years [53.0; 65.0] resp., p=0.03) and had a higher apnea-hypopnea index – AHI (47.7 events/h [37.5; 64.4] versus 38.2 events/h [30.4; 52.7] resp., p=0.04).

Patients with stage III of hypertension were using a PAP device every night significantly less (3.4 h/night [1.1; 3.6] versus 6.3 h/night [5.3; 7.4] respectively, p=0.00) – in comparison with patients with hypertension stages I–II. The adherence of patients with or without coronary artery disease (CAD) and paroxysmal atrial fibrillation (AF) did not differ. There was no significant difference in the incidence of stage III hypertension, CAD, and permanent AF between the groups of adherent and non-adherent to PAP therapy patients.

Conclusion. 63.4% of patients with CVD were adherent to PAP therapy. Adherent patients were older and had a higher AHI. Patients with stage III hypertension were worse adherent to PAP therapy in comparison with patients with hypertension of lesser stages. The CVDs course in adherent and non-adherent patients did not differ.

Systemic Hypertension. 2020;17(4):37-43
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The place of fixed antihypertensive drugs in modern therapy of arterial hypertension
Pinchuk T.V., Orlova N.V.
Abstract

The article provides information on modern approaches to the treatment of arterial hypertension. The historical information about therapy with combined antihypertensive drugs is given. Based on data from multicenter clinical trials, the article provides evidence of the benefits of dual and triple fixed drug combinations. Combinations of â1-adrenoreceptor antagonist bisoprolol and the dihydropyridine-type calcium channel blocker amlodipine are considered. The article highlights the advantages of each of the drugs, as well as their combination. It shows the benefits of a fixed combination of low and medium doses compared to high-dose monotherapy, such as efficacy in achieving target blood pressure, preventing cardiovascular events, increasing adherence to treatment, safety and development of side effects. It provides the evidence base for the effectiveness of a triple fixed combination of renin-angiotensin-aldosterone system blockers with calcium channel blockers and diuretics in achieving target blood pressure compared to a double fixed combination of members of these drug classes, which is due to additive effects. The safety and tolerability profiles were found to be more effective with triple therapy compared with dual therapy, which is also supported by studies.

Systemic Hypertension. 2020;17(4):44-48
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Polymorphism of genes-candidates of renin-angiotensin-aldosteronovy system (ACE, AGT, AGTR1) and effectiveness of treatment of arterial hypertension. Results of research in Mountain Shoria
Mulerova T.A., Morozova N.I., Maksimov V.N., Ogarkov M.Y.
Abstract

Aim. To study the dependence of the effectiveness of antihypertensive therapy on the polymorphic variants of candidate genes of the RAAS (ACE, AGT, AGTR1) in patients with hypertension (АH) of the population of Mountain Shoria.

Materials and methods. In the conditions of the expeditions from 2013 to 2017, the population of Mountain Shoria was surveyed. Included 1409 people 18 years and older. Blood pressure monitoring was carried out as a result of office measurement, according to the standard recommendations of National Guidelines of the Russian Society of Cardiology/the Russian Medical Society on Arterial Hypertension (2010). As a result of the survey, patients with AH were identified for further observation (597 people) who need medical antihypertensive treatment. Repeat screening was conducted in a year. The criterion for inclusion in prospective observation of patients with hypertension was: regular intake of prescribed medication. 253 respondents were surveyed: indigenous (156 people) and non-indigenous (97 people) nationality. All patients underwent a standard examination, including the collection of complaints and anamnesis, an assessment of objective status, laboratory and instrumental studies. Polymorphisms of genes ACE (I/D, rs 4340), AGT (c.803T> C, rs699), AGTR1 (A1166C, rs5186) were tested using polymerase chain reaction.

Results. Dynamic observation of patients with hypertension found that in the cohort of Shors the target level of blood pressure reached the owners of heterozygous I/D and minor D/D genotypes of the ACE gene, carriers of T/C and C/C genotypes of the AGT gene and the homozygous genotype A/A of the AGTR1 gene. In the non-indigenous nationality cohort, only carriers of the D/D genotype of the ACE gene.

Conclusion. National differences were identified with respect to the sensitivity of the pharmacological response to treatment, which once again proves the important role of taking into account the ethnic factor in the choice of drug.

Systemic Hypertension. 2020;17(4):49-54
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Impact of metabolic syndrome parameters and different fat depots on arterial stiffness in patients with abdominal obesity
Andreevskaia M.V., Zheleznova E.A., Zhernakova J.V., Chazova I.E., Shariia M.A., Blinova N.V., Zairova A.R., Azimova M.O., Rogoza A.N., Saidova M.A.
Abstract

Overweight is closely associated with development of cardiovascular disorders. Currently, the terms «metabolically healthy abdominal obesity» (MHAO) and «metabolically unhealthy obesity», i.e., metabolic syndrome (MS) are stated. Comparison target organs status and their link with fat depots in persons of these categories is of important scientific and practical interest.

Aim. To assess arterial stiffness in young people with abdominal obesity with / without MS by various methods as well as its link with various fat stores and other metabolic factors.

Materials and methods. 116 people, 18- to 45-year-old, with abdominal obesity were divided into two groups: MHAO (n=46), aged 40 [34; 43] years and MS (n=70), aged 40 [35; 44] years. The control group (CG) included 16 conditionally healthy volunteers without obesity, aged 32 [27; 35] years (p<0.01). All subjects were assessed for height, body weight, body mass index, and waist circumference. Lipid profile, glucose, 2-hour glucose tolerance test, insulin, leptin, adiponectin, HOMA-IR were determined. 24-hour blood pressure monitoring was performed. Subcutaneous, visceral, perivascular, epicardial fat volumes and, the ratio of subcutaneous fat to visceral fat were determined by computed tomography. Arterial stiffness was determined according to CAVI (Cardio-Ankle Vascular Index), brachial-ankle pulse wave velocity – baPWV (VaSera 1000), aortic pulse wave velocity – aoPWV (EnVisor ultrasound system).

Results. aoPWV were significantly different between groups (p<0.01). In persons with MS: 6.6±1.1 m/s, in MHAO and CG groups: 4.3±0.9 m/s and 5.5±1.0 m/s, respectively. Significant differences in baPWV were found only in MS group 13.8±8.2 m/s (p<0.01) compared with CG and MHAO groups: 10.98±1.2 and 12.3±3.8 m/s, respectively. The CAVI index did not differ significantly between groups. There were reliable relationships between aoPWV and baPWV and almost all MS factors. The highest correlation coefficient was between aoPWV and visceral (r=0.55; p≤0.01) and epicardial (r=0.45; p≤0.01) fats. A close relationship between aoPWV and HOMA IR was revealed (r=0.42; p≤0.01). Correlation analysis showed a higher quality relationship between aoPWV and MS markers, insulin resistance, and fat depots compared to baPWV. According to multivariate regression analysis, the main contribution to the formation aoPWV is made by body mass index, systolic blood pressure, and epicardial fat.

Conclusion. The most sensitive to metabolic factors and the volume of fat depots was aoPWV indicator. Significant differences on some metabolic risk factors and aoPWV between the control group and MHAO raises doubts about the correctness of the term «metabolically healthy obesity».

Systemic Hypertension. 2020;17(4):55-62
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Obesity as a risk factor of contrast-induced acute kidney injury in patients with arterial hypertension and stable coronary artery disease
Mironova O.I., Sivakova O.A., Fomin V.V.
Abstract

Background. The prevalence of obesity in patients with stable coronary artery disease (CAD) and arterial hypertension (AH) is increasing each year. As the number of percutaneous coronary interventions requiring contrast media administration is rising in this group of patients, the risk of contrast-induced acute kidney injury (CI-AKI) remains high. The most important risk factors of CI-AKI in this group of patients remain to be determined as well as their prognostic significance.

Aim. The aim of the study was to assess the role of obesity as a risk factor of CI-AKI in patients with stable CAD and AH.

Materials and methods. 863 patients with stable CAD and AH were included in the prospective open observational cohort study (ClinicalTrials.gov ID NCT04014153). 398 patients were obese and 465 had body mass index (BMI) below 30 kg/m2. CI-AKI was defined as the 25% rise (or 0.5 mg/dl) of serum creatinine from baseline assessed 48 hours after administration of contrast media. The primary endpoint was the development of CI-AKI.

Results. The rate of CI-AKI in patients with obesity was 12.6%, without obesity – 12.7%, but the difference between groups was not statistically significant (p=0.935, 95% CI -0.043–0.046). The rate of CI-AKI in male patients with obesity was higher than in female ones. The logistic regression model of CI-AKI development in patients with stable CAD, AH and obesity was build (AUC 0.9928, р<0,0001, 95% CI 0.9819–1) and included age, weight, body mass index, female gender, heart failure, diabetes mellitus, proteinuria, anemia, baseline creatinine, contrast volume and the difference between baseline serum creatinine and creatinine level after the contrast media exposure. The baseline level of creatinine and the difference between the levels of creatinine before and after contrast media administration were statistically significant risk factors in the model.

Conclusion. The rate of CI-AKI in patients with stable CAD, AH and obesity was 12.6%. The main risk factors of CI-AKI development in multiple logistic regression model were the baseline level of creatinine and the difference between levels of serum creatinine before and after contrast media administration.

Systemic Hypertension. 2020;17(4):63-67
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Efficacy and safety of using a fixed-dose combination of azilsartan medoxomil and chlorthalidone in patients with diabetes mellitus
Zhernakova J.V., Chazova I.E.
Abstract

All resent international and national guidelines for the treatment of patients with arterial hypertension offer a unified approach to the prescription of antihypertensive therapy. The vast majority of patients, including those with diabetes mellitus, require combined drugs. Renin-angiotensin-aldosterone system blockers, calcium channel blockers or diuretics are recommended as first-line therapy. The requirements for diuretics which can be used in this category of patients are especially strong. If patients with diabetes mellitus need diuretics as part of their antihypertensive therapy, thiazide-like diuretics should be preferred. Edarbi® Clo, which is a fixed-dose combination of angiotensin receptor blocker azilsartan medoxomil and thiazide-like diuretic chlorthalidone met all these requirements. Along with its strong antihypertensive effect, Edarbi® Clo has a beneficial effect on metabolism parameters, inflammation parameters and prevents damage to target organs, which makes it possible to recommend it as a drug of choice in this category of patients.

Systemic Hypertension. 2020;17(4):68-73
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Assessment of epicardial adipose tissue by echocardiography for risk stratification in young adults with abdominal obesity
Blinova N.V., Azimova M.O., Zhernakova J.V., Saidova M.A., Ternovoy S.K., Zheleznova E.A., Azimova M.R., Chazova I.Е.
Abstract

The negative role of epicardial adipose tissue (EAT) in the development of cardiovascular diseases makes it possible to use it as a new marker for assessing and predicting cardiovascular risk in obese individuals. Computed tomography (CT) remains the gold standard for determining adipose tissue distribution. However, this method is costly and time consuming. There is a need to search for less expensive and informative methods for visualizing visceral obesity, in particular, EAT.

Aim. To study the link between EAT thickness, measured with echocardiography (EchoCG), and adipose tissue distribution, structural and functional parameters of the left ventricle (LV) in young people with abdominal obesity.

Materials and methods. The study included 104 patients (62.5% women, 37.5% men) aged 18–45 years, with abdominal obesity. In all subjects, height, body weight and waist circumference were measured and body mass index was calculated. EchoCG was performed to assess the LV structural and functional parameters and to determine EAT thickness. The volumes of subcutaneous, visceral, epicardial fat were determined by CT.

Results. Correlation analysis revealed a significant link between EAT thickness, measured with EchoCG, both in systole and diastole, and EAT volume, measured with multispiral CT (EAT in systole r=0.85, p<0.05, EAT in diastole r=0.68, p<0.05). A correlation was revealed between EAT thickness and intra-abdominal fat (EAT in systole r=0.59, p<0.05, EAT in diastole r=0.51, p<0.05). Analysis showed that the greatest contribution to the risk for LV diastolic dysfunction is made by EAT volume. Using ROC analysis, it has been shown that EAT can be used to identify patients with LV diastolic dysfunction.

Conclusion. EAT thickness measured with EchoCG in LV systole closely correlates with EAT and intra-abdominal adipose tissue volumes measured with multispiral CT. EAT thickness in systole more than 7.5 mm, in diastole – 4.0 mm can serve as threshold values for assessing cardiovascular risk in obese individuals.

Systemic Hypertension. 2020;17(4):74-79
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