[Refractory and resistant hypertension in patients with type 2 diabetes mellitus: differences in metabolic profile and endothelial function].

AIM: To determine the prevalence of refractory hypertension (RfH) in patients with and without type 2 diabetes mellitus (DM), as well as to evaluate whether diabetic patients with RfH significant differ from those with uncontrolled resistant hypertension (RH) in clinical phenotype, metabolic profile and endothelial function. MATERIALS AND METHODS: The study included 193 patients with RH: RH 74 patients with diabetes and 119 patients without DM. Uncontrolled RH and RfH were defined by the presence of uncontrolled blood pressure BP (140 and/or 90 mm Hg) despite the use of 3 but 5 antihypertensive drugs (for RH) and 5 antihypertensive drugs, including a mineralocorticoid receptor antagonist (for RfH). Clinical examination, lab tests were performed. Flow-mediated dilation (FMD) and vasoreactivity of middle cerebral artery (MCA) using both breath-holding and hyperventilation test were measured by high-resolution ultrasound. RESULTS: The prevalence of refractory hypertension in patients with and without DM was similar (30% vs 28%, respectively). No differences in BP levels, data of echocardiography and clinical phenotype were found between the diabetic groups, but value of HOMA index, plasma resistin level and postprandial glycaemia were higher in patients with RfH. FMD and MCA reactivity to the breath-holding test were worse in patients with RfH, and they had a more pronounced vasoconstrictor response of MCA to the hyperventilation test compared to patients with RH. CONCLUSION: The prevalence of RfH is the same in patients with and without diabetes. Diabetic patients with refractory hypertension have a more unfavorable metabolic profile and greater impairment of endothelial function than patients with uncontrolled resistant hypertension.

Refractory and Resistant Hypertension in Patients with Type 2 Diabetes Mellitus: Different Response to Renal Denervation.

Aim      To compare the antihypertensive effectivity of renal denervation in patients with diabetes mellitus (DM) and associated refractory arterial hypertension (rfAH) (treated with 5 or more classes of antihypertensive drugs, including a thiazide diuretic and a mineralocorticoid receptor antagonist) and uncontrolled resistant AH (ucAH) (treated with 3-4 drugs).Material and methods  This interventional study with renal denervation included 18 DM patients with rfAH and 40 DM patients with ucAH; 16 and 36 of them, respectively, completed the study in 6 months. At baseline, patients were sex- and age-matched. Study methods included measurement of office blood pressure (BP; systolic/diastolic BP, SBP/DBP); outpatient BP monitoring; evaluation of kidney function (estimated glomerular filtration rate by the CKD-EPI formula); diurnal diuresis volume; diurnal urinary excretion of albumin, potassium and sodium; diurnal excretion of metanephrines and normetanephrines; and plasma levels of glucose and glycated hemoglobin, aldosterone, and active renin. Patients were instructed about maintaining compliance with their antihypertensive and hypoglycemic therapy throughout the study.Results At baseline, patients of both groups were comparable by BP and major clinical indexes, except for higher values of nocturnal SBP variability (p<0.05) in patients with rfAH. At 6 months following renal denervation, both groups displayed significant decreases in office and average daily SBP and also in the "load" with increased mean diurnal SBP. However, the decrease in average daily SBP was almost 4 times greater in the rfAH group than in the ucAH group ( -19.9 and -5.1 mm Hg, respectively, р=0.02). Moreover, 81 % of patients in the rfAH group responded to the intervention (average daily SBP decrease ≥10 mm Hg) while the number of responders in the ucAH group was considerably smaller (42 %; p=0.02). In patients with rfAH, renal denervation was associated with a significant decrease in pulse BP and nocturnal SBP variability and with the increase in diurnal diuresis. No other alterations were noted in laboratory test results in either group.Conclusion      DM patients with rfAH may be the best candidates for the procedure of renal denervation.

[Criteria for selecting patients with resistant hypertension for a renal sympathetic denervation]. / Kriterii otbora bol'nykh s rezistentnoi arterial'noi gipertoniei dlya simpaticheskoi denervatsiya pochek.

AIM: to define and develop a procedure that can select patients with resistant hypertension (RH) for a renal sympathetic denervation (RSD) procedure, by being orienting to the specific initial values of ß-adrenoreactivity (ß-AR) and systolic blood pressure (SBP). SUBJECTS AND METHODS: The analysis included 23 RH patients receiving the maximally tolerable doses of 4 antihypertensive drugs. The investigations involving BP control and a Russian spectrophotometric procedure for determining ß-AR in terms of the change in the osmoresistance of erythrocyte membranes (EM) were performed at baseline and 4 and 24 weeks. RSD was carried out using endovascular radiofrequency ablation of the renal arteries. The therapy was not changed during the observation. RESULTS: If SBP was >170 mm Hg and ß-AR of EM >40 conditional units (CUs) at baseline, ΔSBP was 17.68±3.24 mm Hg and the efficiency of RSD was 100%. When SBP was <170 mm Hg and ß-AR of EM <40 CUs at baseline, ΔSBP was 0.97±4.21 mm Hg (p>0.05) and the efficiency of RSD was low. CONCLUSION: The overall estimate of baseline SBP and ß-AR of EM in patients with RH could determine the expediency of the RSD procedure in order to lower BP. The proposed procedure can optimize the selection of patients and enhance the efficiency of RSD in the treatment of RH.

[Possibility of evaluating the effectiveness of renal artery sympathetic denervation in resistant hypertension early after radiofrequency ablation]. / Vozmozhnost' otsenki effektivnosti simpaticheskoi denervatsii pochechnykh arterii pri rezistentnoi arterial'noi gipertonii v rannie sroki posle provedeniya radiochastotnoi ablyatsii.

AIM: to investigate time course of changes in the adrenoreactivity (AR) of erythrocyte membranes (EM) after radiofrequency ablation of the synaptic nerves of the renal arteries (RA) in patients with resistant hypertension (RH) and to assess whether this indicator can be used for the early evaluation of the efficiency of an invasive intervention into the RA. SUBJECTS AND METHODS: 24 patients with RH, who received full-dose antihypertensive therapy with at least three drugs, including a diuretic, were examined. Renal sympathetic denervation (RSD) was carried out by endovascular radiofrequency ablation (RFA) of the RA. 24-hour blood pressure (BP) monitoring and determination of the ß-adrenoreactivity (ß-AR) of EM were performed, by taking into account the change in erythrocyte osmoresistence at baseline and 1 and 24 weeks after RFA. The therapy was not changed during the observation. RESULTS: The patients included in the study were divided into 2 groups. One week following RSD, 15 patients of Group 1 were noted to have a decrease in the ß-AR of EM by 10 conditional units or more; average daily systolic BP (SBP) and diastolic BP (DBP) reduced by 8.3 and 2.8 mm Hg, respectively. In 9 patients of Group 2, the ß-AR of EM was unchanged in this observation period or increased compared with baseline. In this group, the decrease in average daily SBP and DBP was noted to be less pronounced than that in Group 1 (by 1.4 and 1.5 mm Hg, respectively). At 24 weeks after RSD, Group 1 was seen to have an effective daily decrease in average daily SBP and DBP by 25.6 and 14.3 mm Hg, respectively (p=0.01 and 0.05). The average value of the ß-AR of EM significantly declined compared with baseline. In Group 2, no statistically significant changes were reported; SPB and DBP lowered by 7.0 and 3.0 mm Hg, respectively. There was a significant decrease in the ß-AR of EM compared with that at week 1. CONCLUSION: The decline in the ß-AR of EM within the first week after RFA is suggestive of the decreased activity of the sympathoadrenal system and may be used as an early efficiency index of RSD after the procedure.

[Cerebrovascular reactivity in patients with rheumatoid arthritis concurrent with and without hypertension].

AIM: To compare cerebrovascular reactivity (CVR) in patients with rheumatoid arthritis (RA) concurrent with essential hypertension (Group 1) and in those with RA and normal blood pressure (BP) (Group 2). SUBJECTS AND METHODS: During the study of Groups 1 (n = 37) and 2 (n = 12), the investigators estimated the prevalence of traditional cardiovascular risk factors, performed 24-hour BP monitoring, investigated CVR by transcranial Doppler (TCD) of the middle cerebral arteries (MCA) by hyperoxic and hypercapnic tests, and endothelium-dependent vasodilation (EDV) and endothelium-independent vasodilation of the brachial artery. The groups were matched for gender, age, RA activity and stage, and antirheumatic therapy volume. RESULTS: According to the results of MCA TCD, the hyperoxic test recorded impaired CVR in 34 (92%) and 10 (83%) patients in Group 1 and 2, respectively; the hypercapnic test revealed this condition in 19 (51%) and 6 (50%) patients in these groups, respectively. The hyperoxic test most commonly showed an insufficient decrease in MCA linear blood flow velocities (LBFV) in 31 (84%) and 8 (66%) patients in Groups 1 and 2, respectively; the hypercapnic test did an excessive increase in MCA LBFV in 12 (32%) and 4 (33%) patients, respectively. There was a high rate of impaired EDV in 32 (86%) and 9 (75%) patients in Groups 1 and 2, respectively. CONCLUSION: According to the results of MCA TCD, there were high and similar rates of impaired CVR in patients with RA concurrent with and without essential hypertension during the hyperoxic and hypercapnic tests.

[Noninvasive assessment of functional competence of the radial artery as a possible vascular graft for coronary artery bypass grafting].

Described herein is a variant of surgical treatment of a patient presenting with type A aortic dissection extending to the brachiocephalic branches accompanied by thrombosis of the false channel of the latter. In the rare cases in dissection and thrombosis of the brachiocephalic branches for adequate protection of the body (systemic protection) it is necessary to use bidirectional arterial perfusion under the conditions of moderate hyperthermia: through a preliminarily sewn into the carotid artery prosthesis - perfusion of the brain, through cannulated aortic arch or femoral artery - body perfusion.

[Consistence of the radial artery as a conduit used in aortocoronary bypass surgery, a possibility of preventing shunt spasm].

AIM: To develop a new procedure to evaluate the functional consistence of the radial artery (RA) as a conduit used in aortocoronary bypass surgery (ACBS), to verify the prognostic value of the changed diameter of RA, and to prevent its spasm. SUBJECTS AND METHODS: The study enrolled 34 patients aged 59.4 +/- 8.6 years with coronary artery stenoses, who underwent ACBS using a RA conduit. While preparing them for surgery, endothelium-dependent vasodilation (EDVD) of RA, i.e. the magnitude of a change in its diameter (deltaD) was assessed; RA tone and nitric oxide (NO) concentrations were estimated during surgery; RA EDVD was re-estimated in 12 lercanidipine-treated patients with deltaD < 8%. RESULTS: The patients were primarily divided into 2 groups: 1) deltaD > or = 8% (RA spasm intra- and postoperatively); 2) EDVD deltaD < 8% (RA spasm). Significant differences between Groups 1 and 2 were intraoperatively recorded in vascular wall tone (U = 1.0; Z = -2.3; p = 0.02) and NO concentrations (p = 0.0); a relationship was found between these parameters. After lercanidipine treatment, the degree of deltaD = 4.36 +/- 1.89% increased to 11.32 +/- 2.22% (p = 0.0) and RA tone dropped from -1.68 to -3.9 mm in Group 2a with the baseline decreased vasodilating activity of RA. CONCLUSION: Ultrasound assessment of the vasodilating activity of RA provides adequate evidence about its arterial wall tone during surgery. deltaD < 8% is prognostically unfavorable and serves as a contraindication to the use of RA as a conduit during ACBS. The administration of lercanidipine allows effective correction of the dilatory capacities of an arterial conduit.

[Indapamide retard and enalapril in patients with arterial hypertension: hypotensive effectiveness and effect on endothelial function].

AIM: To find out what type of therapy was better for restoration of 24 hour blood pressure (BP) rhythm and impaired function of vascular endothelium, and to determine preferential therapy for patients with severe endothelial dysfunction. METHODS: We performed ambulatory blood pressure monitoring and assessments of endothelial dependent (flow mediated-FM) and endothelial independent (nitroglycerine) dilatation of forearm artery (DFA) in patients with stage I-III essential hypertension. In a randomized comparative cross-over study 76 patients (mean age 49.2 +/- 6.2 years) received indapamide retard 1.5 mg and enalapril 20 mg for 24 weeks. RESULTS: Hypotensive effect of both drugs was identical (indapamide lowered systolic/diastolic BP by 13.6/12.0% and 12.9/9.9%, enalapril lowered BP by 14/14.6% and 13.2/12.9%). BP rhythm was better transformed by treatment with indapamide: nocturnal fall of mean BP increased on indapamide from 8.1 +/- 6.9% at baseline to 12.8 +/- 5.0% after treatment, p=0.007, and on enalapril from 11.8 +/- 7.9% at baseline to 10.4 +/- 6.2% after treatment, p=0.2. Indapamide and enalapril significantly augmented FM DFA (from 4.7 +/- 2.8% to 9.03 +/- 3.47%, p < 0.001, and from 4.6 +/- 2.2% to 10.9 +/- 3.5%, p < 0.001, respectively). All patients were divided into 2 groups: with baseline FM DFA - 2.5% (group I, n=59) and < 2.5% (group II, n=16). In group II indapamide lowered BP more effectively than enalapril ( - 10.2/ - 9.1% and - 5.5/ - 5.2%, p < 0,01/0.01, respectively). CONCLUSION: Both indapamide retard 1.5 mg and enalapril 20 mg exerted normalizing action on endothelium dependent DFA. However indapamide transformed 24 hour BP profile better than enalapril. Hypotensive therapy with indapamide was more effective than therapy with enalapril in patients with more pronouncedly disturbed FM arterial vasodilatation. This can be used in selection of a preparation in patients with impaired FM vasodilatation.

[Correlation between the parameters of 24-hour monitoring of arterial pressure and changes in arterial wall structure based on the results of a prospective trial].

AIM: To evaluate prognostic value of 24-h monitoring of blood pressure (BPM-24) for assessment of structural changes in arterial walls in patients with essential hypertension living in West Siberia. MATERIAL AND METHODS: In the course of 5-year prospective study we made two extended clinical and device examinations with use of BPM-24 and ultrasonic measurements of arterial intima-media complex (IMC) in 160 patients (mean age 48.97+/-8.18 years). RESULTS: An independent significant correlation was found between initial drop of the circadian index (CI) of blood pressure, systolic blood pressure (SBP)/diastolic blood pressure (DBP) at night (r = 0.24/0.22, p = 0.012/0.024) and thickness of IMC in 5 years (r = -0.28/-0.30, p = 0.004/ 0.002). The risk of increased thickness of arterial wall in the group with abnormal CI was 1:4. There was no relationships between IMC increase and baseline office blood pressure (r = 0. 18/0.12, p = 0. 057/0.188). In evaluation of office BP effects on progression of arterial atherosclerosis insignificant correlation coefficients for SBP/DBP were obtained (r = 0. 18/0.18, p = 0. 150/0.149) contrary to BPM-24 parameters: mean circadian SBP (r = 0.22, p = 0.046) and heart rate (r = 0.23, p = 0.038), SBP temporal index for 24 hours (r = 0.24, p = 0.035). CONCLUSION: . BPM-24 parameters are more significant predictors of structural changes in arterial wall than standard office blood pressure. This allows calculations of possible risk of such changes.

[Recognition of actual periods of nocturnal rest from 24-hour heart rate profile].

UNLABELLED: Inability to delineate exactly periods of nocturnal sleep and diurnal wakefulness during 24-hour blood pressure (BP) monitoring causes reporting of erroneous BP values for these periods. We suggested a simple mathematical algorithm for detection of periods of nocturnal rest determined as period of low values of cardiac rhythm using data of BP monitoring itself. AIM: To compare novel method of recognition of periods of sleep with 2 standard techniques: use of fixed time interval between 23 and 7 hours (1), or period of sleep according to patient's diaries (2). Reproducibility of nocturnal BP lowering between two 24-hour intervals during 48-hour blood pressure monitoring was used as a measure of precision of determination of diurnal/nocturnal BP. METHODS: Ambulatory 48-hour BP monitoring was carried out in 33 patients with uncomplicated stage II hypertensive disease. Automatic analysis of BP monitoring data was performed with the use of specially designed computer application. Standard deviation (SD) of differences (SDD) between pairs of nocturnal BP lowering during 48 hours was used as a measure of reproducibility. RESULTS: Reproducibility of values obtained with novel algorithm (SDD for systolic/diastolic BP 6.7/8.2 mm Hg) was substantially better than those obtained with standard methods (1) and (2) (SDD 13.0/14.8 and 13.5/18.3 mm Hg, respectively). CONCLUSION: The proposed method of recognition of the period of nocturnal rest substantially improved precision of automatic analysis of 24-hour BP monitoring.

[Function of the brain venous system and a 24-h profile of arterial pressure in hypertensive patients].

AIM: To study blood flow along the internal jugular veins (IJV) in the initial state and under the action of nitroglycerin in patients with essential arterial hypertension (EAH) with reference to characteristics of a 24-h profile of blood pressure. MATERIAL AND METHODS: A 24-h monitoring of blood pressure (MBP), duplex scanning of IJV, venous IJV outflow were studied in 26 patients with EAH stage 2 (mean age 39 +/- 5.0) before and after sublingual intake of nitroglycerin (0.5 mg). RESULTS: By 24-h MBP findings, two groups of patients were identified: with unaffected blood pressure profile (group 1) and affected profile (group 2). Nitroglycerin produced a unidirectional reaction of IJV (increased outflow) in group 1 and multidirectional changes of venous outflow along the IJV in patients of group 2. CONCLUSION: Nitroglycerin test showed different venous cerebral hemodynamics in EAH patients with different variants of 24-h MBP.

[Relationship between changes of endothelial vasodilator function, vascular and cardiac structure and derangements of blood pressure 24-hour profile]. / Sviaz' izmenenii vazodilatatornoi funktsii éndoteliia, struktury sosudov i serdtsa s narusheniem sutochnogo profilia arterial'nogo davleniia.

AIM: To assess relationship between 24-hour blood pressure (BP) rhythm and structural and functional state of the heart and blood vessels. MATERIAL AND METHODS: Echocardiography, sonography of carotid artery intima-media, and assessment of endothelium dependent (flow mediated) and endothelium independent (nitroglycerine) brachial artery vasodilatation were used in the study of 83 patients with stage I-II essential hypertension (mean age 49.2+/-6.2 years). Seventy four patients received indapamide and enalapril for 24 weeks. RESULTS: According to results of 24-hour BP monitoring the patients were divided into 2 groups with normal (dippers) and abnormal (non-dippers) BP rhythm. Non-dippers compared with dippers had more pronounced lowering of endothelium-dependent autoregulation of arterial tone, bigger left ventricular mass thicker carotid artery wall. Linear correlation was found between changes of 24-hour BP rhythm and structural and functional parameters of the heart and vessels. More pronounced regression of their derangements occurred during antihypertensive therapy in those patients in whom normalization of 24-hour rhythm was achieved.