[HYPERTENSIVE CRISIS: MODERN VIEW OF THE PROBLEM AND OPTIMIZATION OF DIAGNOSTIC AND THERAPEUTIC MODALITIES].

The data collected by Burdenko Military Hospital indicate that in the 1980s hypertensive crisis (HC) occurred in roughly 30% of the patients with AH. This value fell down to 16% by 2012, with a rise in the number of uncomplicated crises from 46 to 62%. Analysis of the causes behind these changes showed that half of the patients simply experienced an elevated arterial pressure with minimal clinical symptoms. The decrease in the number of complicated cases from 54 to 39% is doubtful bearing in mind that ICD-10 gives the status of nosological entities to complications of hypertensive crisis (stroke, myocardial infarction, etc.) but not to the HC syndrome proper requiring urgent hospitalization; due to this hypertensive crisis itself tends to be disregarded and not included in statistics. HC with acute clinically significant lesions of target organs requires intensive care or resuscitation using infusion of vasodilators and loop diuretics to stabilize arterial pressure. In case of uncomplicted HC and aggravation of hypertensive disease, the medications of choice are oral short-acting ACE inhibitors and imidazoline receptor agonists.

[Emergency state of health by arterial hypertension].

Emergency state of health by arterial hypertension. According to the Burdenko Main Military clinical hospital at the present time the frequency of crisis hypertensive heart disease is 16% from the total number of all patients with this nosology. Rapid relief of hypertensive crisis should be provided for patients' status assessment from the position of development of fatal complications. Herewith the main task when treating hypertensive crisis is not normotension, but reduction of blood pressure to safe level, taking into account potential risk of hypotonia and hypoperfusion in case of too aggressive hypotensive therapy. The main factor of hypertensive crisis development is the absence of compliance. The authors gave recommendations on treatment of complicated and non-complicated forms of hypertensive crisis, and provided indications for hospitalization.

[New approaches to the diagnosis, treatment and rehabilitation of military personnel, military pensioners and their family members with arterial hypertension].

The article considers new approaches to diagnosis, treatment and rehabilitation of patients with arterial hypertension (AH) applied to the Ministry of Defence contingent. For the medical service of the Armed Forces the problem is relevant because of the significant labor losses, high level of dismission, morbidity and mortality of this disease. In the assessment of the patients limitation of life should be considered a variant AH, the stage, availability and seventy of the organ damage, severity and reversibility of complications, the incidence and severity of hypertensive crises, the effectiveness of treatment, comorbidity, education, occupation, the presence of contra-types and conditions of military service or labor. Military medical expertise of soldiers with AH uses the classification of degrees of arterial hypertension of 2010 and a three-stage-classification hypertonic disease created by the World Health Organization, 1996.

[Refractory hypertension: diagnosis and treatment optimization].

Resistant hypertension occurs in up to 15% of patients with arterial hypertension in Russia. Medical treatment of resistant hypertension must include minimum 3 medications with maximum or maximum tolerated doses besides one of the medications must be diuretic. According to department of arterial hypertension of the Burdenko Main Military Clinical Hospital to achieve the target levels of arterial blood pressure it was necessary to prescribe 4-5 components antihypertension therapy in patients. Authors suggested an algorithm of diagnosis and treatment of patients with resistant hypertension with the help of surgical method. This method is based on decreasing of sympathic nervous system activity by selective break of neuronal connections with the help of interventional intravascular radio-wave ablation. Endovascular renal sympathetic denervation allows to effectively control arterial blood pressure, to optimize antihypertensive therapy, but this method does not cure from arterial hypertension.

[Clinical evaluation of the influence of certain initial status parameters on the development of type 2 diabetes mellitus in patients with metabolic syndrome].

Type 2 diabetes mellitus (DM2) is one of the clinical outcomes of metabolic syndrome (MS). We observed 201 patients with MS during 10 years. At the study end-point 144 (71.9%) of them developed DM2. The study aimed at evaluating effect of initial parameter of MS on the rate of DM2 development. Results of correlation analysis show that the rate of DM2 development depends in the first place on the patients' age, severity of abdominal obesity, vicious habits and their combination with disturbed lipid metabolism, sympatho-adrenal disbalance , and arterial hypertension rather than on disordered carbohydrate metabolism at the onset of the disease.

[The first experience with the use of catheter denervation of renal arteries in patients with refractory hypertension].

The prevalence of refractory arterial hypertension in Russia is estimated at 15%. We report the first experience with surgical treatment of this pathology. The method is based on the reduction of activity of the sympathetic nervous system by selective breaking of connections between of neurons with the help of interventional intravascular radiowave ablation. Renal endovascular sympathetic denervation allows to more effectively control AP and optimize antihypertensive therapy but does not ensure recovery from AH.

[Evolution of treatment options for hypertension].

In the early 20th century hypertension became a medical problem because of the prevalence. The process of clinical research of the etiopathogenesis of hypertension is associated with a scientific and technical progress and state of medical science at every historical stage. The first stage (end of the 19th century--beginning of the 20th (century) was characterised by a research of hypertension and monitoring of its natural history. The second stage (early--mid 20th century) was characterised by attempts to influence on the natural history of hypertension. The basis of the attempts was neurohumoral concept. The third stage (end of 50s--beginning of 70s)--was characterised by the application of angiotensin-converting enzyme inhibitor, calcium channel blocker and thiazide diuretic along with beta-adrenergic blockers. The fourth stage (end of 20th century--beginning of 21st) was characterised by discovery of the renin-angiotensin-aldosterone system, development of complex treatment options for hypertension, based on stratification of risk factors of cardiovascular complication. Clinical picture of hypertension haven't changed significally during the last 100 years. Cerebral and cardiac manifestations of hypertension remain dominat in 21st century as well as in 20th century. In the beginning of 21st century such systems as eyes and kidneys are not affected by the hypertension. Hypertension remains the main cause of progression of cardiac muscle and vessel wall structural changes.

[Alterations in the clinical course of hypertensive disease during the last 25 years].

We undertook analysis of 234 case histories of the patients with HD dated 1985-1987 (group 1) and 2010-2012 (group 2). It showed differences in clinical manifestations of HD between the two periods. First, "cerebral" complaints were less frequent in group 2 while functional state of the cardiovascular system (tolerance of physical load) and efficacy of hypotensive therapy improved. Second, decreased AP did not exclude progression of atherosclerosis and its complications in the presence of other risk factors. MS components (increased body mass, dyslipidemia, hyperglycemia) were more common in group 2 which suggests the necessity of combined prophylaxis of cardiovascular catastrophes. Third, changes in daily AP profile in group 2 require more extensive use of 24 hr AP monitoring for the choice of hypotensive therapy and estimation of its efficacy at specified time. Fourth, modern methods for the treatment of AH slow down the development of renal symptoms of AH.

[Hypertensive crisis: problems of diagnostics and paradigm of the treatment].

Analysis of causes of increase of the uncomplicated hypertensive crisis (HC) from 46 to 61% indicates that in the half of cases the cause was only high ABP with minimal clinical symptomatology. To refer all cases of the catadrome of hypertensive disease to hypertensive crisis is inappropriately. It is recommended to use with such concepts as "complicated" and "uncomplicated" HC also term "catadrome of hypertensive disease (instability of ABP)". It allows to except the hyperdiagnosis of HC and to optimize indication for hospital admission. There are recommendations for medical actions in case of complicated and uncomplicated HC and catadrome of hypertensive disease.

[Cutaneous-visceral interplay in patients with systemic lupus erythematosus].

Systemic lupus erythematosus (SLE) remains a challenging medical problem. The integral approach to the analysis of underlying pathogenetic processes allows identifying main symptom complexes of SLE and establishing relationship between skin lesions and activity of the disease. We examined 84 patients with SLE (84% women), their mean age was 42.3 +/- 2.3 yr duration of SLE 6.5 +/- 1.2 yr. The subacute and chronic SLE variants were diagnosed in 30 (36%) and 54 (64%) patients respectively. Grade 1 and 2-3 inflammatory process occurred in 53 (63%) and 31 (37%) patients respectively. Symptom complexes "systemic inflammation", "butterfly rash", "wrist petechiae", "enanthema of the oral mucous membrane", and other lesions were regarded as the markers of SLE activity. The relationship of lupus-cheilitis and facial erythema with polyserositis and pericarditis ("visceral pathology-cardiovascular lesions") requires instrumental examination of pericardium, pleural and abdominal cavities in the patients with the above skin symptoms for diagnostics of polyserositis. At the same time, the presence of teleangiectasia on the wrists (symptom complex "visceral pathology-renoparenchymatous lesions") requires thorough examination of the renal function. The presence of erythema at the major joints, mesh livedo, and Raynaud's syndrome (symptom complex "musculoskeletal disorders") implies specialized examination of the locomotor apparatus.

[Systemic lupus erythematosus: correlation of cutaneous manifestations with disease activity].

Results of treatment of 84 patients with systemic lupus in specialized units of the Main Military Clinical Hospital n. a. N.N.Burdenko erythematosus are performed. Subacute variant of the disease was diagnosed in 36% of patients, chronic - 64%. Active inflammation grade 1 was observed in 63% of patients, 2-3rd class - 37%. Between changes in the skin and the degree of inflammatory activity, variant of the disease set a definite relationship. The data obtained allowed to propose a diagnostic algorithm in systemic lupus erythematosus in order to optimize the therapeutic effects.

[Hypertensive disease: diagnostics and differential methods of antihypertensive therapy].

Diagnostics of hypertensive disease is performed according two-stage scheme recommended by Society of cardiology of Russian Federation (2010) and adapted by us for examination in Central Military Clinical Hospital n. a. N.N. Burdenko. First stage, as possible, should be carried out in out-patient departments, second stage, as it necessary, in specialized medical treatment facilities. Indications for admission of patient with hypertensive disease are abstrusity of diagnosis and necessity of carrying out of special, often invasive study, for updating of information about the form of arterial hypertension, difficulties in adjustment of antihypertensive therapy. Major criterion for adjustment of antihypertensive therapy is degree of cardiovascular risk. In the beginning of treatment monotherapy is preferable for patients with low and average risk of progression of cardiovascular disease, use of combination of two or three medications in small doses is reasonable for patients with high and very high risk of complications. Three medications were prescribed for 21% of patients, four or five for 14% of patients.

[Possibilities of early surgical correction of postinfarction remodeling of the heart].

Postinfarction remodeling of the heart (PIRH) has unfavorable prognostic value because is associated with elevated risk of fatal arrhythmias, emergence and progression of heart failure. Reversibility of PIRH in early period after myocardial infarction causes interest. We followed dynamics of echocardiographical parameters in a patient who had undergone myocardial infarction with subsequent aorto-coronary bypass operation. Values of left ventricular end diastolic and end-systolic volumes were as follows: baseline - 147 and 70, in the process of infarction - 281 and 141, in 1 month after infarction - 298 and 194, in 10 days after surgery - 194 and 88, in 1 year after surgery - 194 and 83 ml, respectively. Thus PIRH is substantially reversible in the early period after myocardial infarction followed by adequate cardiac muscle revascularization. In can be supposed that at the moment of infarction an abrupt progression of stenotic atherosclerosis of the coronary arteries occurs due to complete or subtotal occlusion of vessels, what aggravates myocardial ischemia and predominantly determines course of subsequent PIRH.

[Clinical and morphological characteristics and factors of prognosis of pulmonary thromboembolism].

Analysis of 146,521 autopsy protocols in Moscow in 2001-2005 showed that the incidence pulmonary thromboembolism (PTE) as a direct cause of death was 3.8-7%. PTE was not diagnosed during life in 20-28% of the patients who had died at hospitals and in 68-72% of those who had died at home. PTE was 2-3 times more common in females than in males, the age of the deceased patients was old and senile. The sources of PTE were thrombi of the leg deep veins (93.2%), small pelvic veins (3.4%), and right heart chambers (1.1%). Thrombophilic states were one of the main causes of the poor course and outcome of PTE. Based on the studies performed, an algorithm was developed for the diagnosis and treatment, which was successfully used at the N.N. Burdenko Main Military Clinical Hospital. The introduction of the results could reduce the incidence venous thrombosis from 39% to 17%, that of cava-filter thromboses from 24% to 3.7%, and recurrent TELA from 15% to 5.6%.

[Arterial hypertension: the modern therapeutic strategy].

Arterial hypertension (AH) is a serious social and medical problem of our time. The review presents approaches to antihypertensive therapy taking into account the degree of cardiovascular complication risk; the main principles of pharmaceutical correction of AH are formulated.

[Pulmonary arterial thromboembolism and thrombophilias: optimization of diagnostics and treatment].

The subjects of the study were 94 patients with pulmonary arterial thromboembolism (PATE). The prevalence of thrombophilic conditions (TC) among these patients was studied, and their role in the development of an unfavorable clinical course of PATE was evaluated. A three-year prospective study revealed that pre-thrombotic conditions had been diagnosed in 90% of PATE patients. There is a strong correlation between an unfavorable course of PATE and the presence of isolated or combined genetic mutations, or a combination of those with an increase of factor VIII level, and a high titer of cardiolipin antibodies with a mutation in factor V gene. Occurrence of PATE in patients less than 40 years of age who suffer from an idiopathic type of venous thrombosis and have a family background of thrombophilic conditions, which requires a detailed hematological examination, is a predictor of unfavorable course of PATE in the post-hospital period. Purposeful pharmaceutical correction of thrombophilic conditions lowers the frequency of venous thrombosis recurrence from 39% to 17%, the frequency of cava-filter thrombosis recurrence from 24% to 3.7%, and the frequency of PATE recurrence from 15% to 5.6%.