Resistant Arterial Hypertension Research Articles

EFFECT OF RENAL DENERVATION ON THE PLASMA ADIPONECTIN CONCENTRATION IN PATIENTS WITH RESISTANT HYPERTENSION

Objective: Adiponectin is produced by white adipose tissue and has anti-diabetic, anti-atherosclerotic, anti-thrombotic, anti-inflammatory, and cardioprotective properties. In patients with arterial hypertension plasma concentration of adiponectin is lower than in healthy subjects. Renal denervation (RDN) i.e. percutaneous ablation of fibers from the sympathetic nervous system located in the wall of the renal arteries by radio frequency waves, is a method of resistant arterial hypertension treatment. The aim of this single center, interventional, clinical study was to assess the effect of RDN on the plasma adiponectin concentration in patients with resistant arterial hypertension. Design and method: Twenty-six patients (12 women, 14 men) aged 54.0±7.8 years with resistant hypertension who underwent RDN using Simplicity catheters (Medtronic, Inc., Northridge, CA) were enrolled in the study. Plasma adiponectin concentration was determined using the Human Adiponectin ELISA Kit (Otsuka Pharmaceutical Co, Tokyo, Japan) before the RDN and 6 and 12 months after this procedure. Results: Blood pressure (BP) values before RDN and 6 and 12 months after RDN were as follow: systolic BP - 190.4±24.5, 160.8±14.5, 155.7±17.9 mmHg (p<0.001) and diastolic BP - 111.7±18.9, 88.9±8.3, 91.2±10.2 mmHg (p<0.001), respectively. Body mass index (BMI) before RDN, 6 and 12 months after RDN were 31.5±4.2, 30.5 ±4.4, 30.2±4.0 kg/m2, (p = 0.057), respectively. Plasma adiponectin concentration before the RDN and 6 and 12 months after RDN were 6.93±4.85, 7.94±3.97, 8.83±6.12 [μg/ml] (p = 0.007), respectively. In the follow up i.e. 6 and 12 months after RDN plasma adiponectin concentration increases significantly in responders (systolic BP decrease higher or equal 25 mmHg) (7.93±6.14, 8.87±4.68, 10.57±7.51 [μg/mL]; respectively]; p = 0.03, and did not change significantly in low-responders to RDN (systolic BP decrease < 25 mmHg) (5.76±2.45, 6.86±2.76, 6.81±3.19 [μg/mL]; respectively; p = 0.2). Conclusions: 1. Plasma adiponectin concentration increases significantly after successful RDN in patients with resistant arterial hypertension. 2. Higher plasma adiponectin concentration may participate - beyond blood pressure reduction - in the cardiovascular benefits related to successful RDN, however clinical consequences of our results need further investigations.

RELATIONSHIP OF T704C AGT GENE POLYMORPHISM WITH RESISTANT ARTERIAL HYPERTENSION IN UZBEK POPULATION

Objective: to study the association of T704C polymorphism of AGT gene with resistant arterial hypertension (AH) in Uzbek population. Design and method: Study included 178 patients with AH I–III degree of both sexes. The mean age of patients was 57.15 ± 11.01 years, duration of AH was 9.55 ± 5.75 years. Genotyping of the T704C polymorphism of the AGT gene was performed using real-time PCR using gene-specific primers of allele-specific probes. Relative risk (RR) was calculated using genetic models. Calculations were performed using the online program “Calculator for calculating statistics in case-control studies”. The results of all studies were considered statistically significant at p<0.05. Results: Patients were divided into two groups: 1 - patients with resistant AH (cases, n = 61) and 2 - patients with controlled hypertension (controls, n = 117). TT genotype - determined in 16.4%, TC genotype - in 32.8%, CC genotype - 50.8%, 2 = 16.279, p = 0.000. The allelic distribution showed the predominance of C allele: C allele - 67.2%, T allele - 32.8%, ⇙2 = 27.557, p = 0.000. In group 2, C allele in 52.6%, T allele in 47.4%, respectively, ⇙2 = 1.034, p = 0.309. The ratio of TT:TC:CC- genotypes was as follows: 20.5%: 53.8%: 25.6%, ⇙2 = 33.923, p = 0.000. An analysis revealed an association of the C allele T704C of the AGT gene polymorphism with resistant AH. 61 patients with resistant AH of group 1, the C allele was more common than in patients with of group 2 (67.2%; ⇙2 = 7.05; P = 0.008; OR = 1.85, 95% CI 1.17-2.92) and 32.8% had T allele. Accumulation of CC genotype among patients of group 1 (50.8%; ⇙2 = 11.59; P = 0.003; OR = 3.00, 95% CI 1.56-5.75), while TC genotype was found in 32, 8% of cases and TT genotype in 16.4% of cases. Whereas in the 2nd group, the CC genotype was less common - in 25.6% of cases than the TCgenotype (53.8%) cases. Conclusions: The results obtained indicate a significantly greater accumulation of the C-allele of T704C polymorphism of the AGT gene among patients with resistant hypertension. The C allele and CC genotype T704C of AGT gene polymorphism are associated with resistant hypertension in the Uzbek population.

RENAL DENERVATION IN PATIENTS WITH RESISTANT HYPERTENSION: FOLLOW UP 2011-2021 OF THE SERIES OF THE ESH CENTER OF EXCELLENCE IN TURIN

Objective: Renal denervation (DRN) is one of the invasive therapeutic approaches of resistant arterial hypertension. The aim of this study was to re-evaluate patients undergoing DRN, in terms of safety and efficacy. Design and method: A retrospective evaluation of patients undergoing DRN between 01/01/2011 and 31/12/2021 in the Arterial Hypertension Center of Turin. Results: The series included 14 subjects, of which 8 (57%) were female and with an average age 54±10 years. The number of antihypertensive drugs before renal denervation was 5.7±1.0 and at baseline the blood pressure was 188/113±22±18 mmHg. 28% of subjects had a history of ischemic heart disease and 27% of previous stroke and/or transient ischemic event. 9 subjects were denervated with Symplicity device, 1 with Vessix, 4 with Symplicity Spyral. The mean duration of follow-up was 5.2 years. From a safety point of view, there were no short-term or long-term complications. In terms of efficacy, the number of responders at 6 months, defined as a reduction of at least 10 mmHg in systolic blood pressure (PAS) at 24h Blood Pressure Monitoring, was 9 subjects (64%). Two subjects reported systolic blood pressure values below 135 mmHg. Regarding the type of device used, 75% of subjects treated with Spiral devices were responders, compared with 60% of subjects treated with other catheters. Among the non-responders, 2 presented events one year after the DRN. Only 1 responder had high level of renin at baseline. Conclusions: The data relating to the case studies of the Arterial Hypertension Center of Turin highlight the safety of the renal denervation procedure and a blood pressure response in 60% of patients. The latest generation catheters seems to be more effective. However, the small number of cases did not allow to identify predictive factors of response to DRN.

Predictors for success of renal denervation in patients with resistant arterial hypertension

Objective. Development of principles for personalized selection of patients for renal denervation (RD) based on the evaluation of procedural response predictors. Design and methods. In the period from 2016 to 2022, 91 patients with resistant arterial hypertension (RHTN) underwent a RD procedure using 2 types of catheters — monopolar and spiral. All patients were assessed for basic demographic, clinical, functional, and laboratory characteristics. The reassessment was carried out on the 7th day, then after 6 and 12 months. A predictive model for determining the probability of response to RD was constructed using the logistic regression method. Results. The final analysis included data from 91 RHTN patients, the mean age was 57,79 ± 9,5 years. At baseline, patients received 4,5 ± 1,4 antihypertensive drugs. Initial office systolic blood pressure (SBP) was 190 (interquartile range (IQR) 100; 140, 240) mm Hg, diastolic blood pressure (DBP) — 100 (IQR 60; 80, 140) mm Hg. Among the responders, a significant reduction in blood pressure (BP) was achieved, with maintenance of the antihypertensive effect during 1 year of follow-up (p < 0,001 for SBP and DBP). The multivariate regression analysis showed that the initial DPB (p < 0,001), the diameter of the right (p = 0,049) and left renal arteries (RA) (p = 0,038) were significant predictors. Based on these data, a prognostic model was developed (p < 0,001). Conclusions. Our results confirmed effectiveness and safety of RD. The stability of the clinical effect is important. However, there was a high variability in the degree of BP reduction after the procedure. The initial DBP, the diameter of the left and right RA, and the use of drugs that reduce the activity of the sympathetic nervous system can be used as possible predictors of response to RD.

Прихильність до лікування в пацієнтів з резистентною артеріальною гіпертензією

The aim – to identify patients with true resistant arterial hypertension and to assess patients’ adherence to treatment on the background of a fixed combination of antihypertensive drugs.Materials and methods. 1146 patients with resistant hypertension were included in the study. Men and women over the age of 18 were included, provided that the average level of office blood pressure (BP) was greater than 140/90 mm Hg, when taking 3 or more antihypertensive drugs. Morisky – Green Questionnaire (in a modified scale) (MMAS-8) on patient adherence to treatment. To determine adherence to treatment in some patients, determination of drugs in urine was carried out in the central laboratory. All patients were initially subjected to the following tests: measurement of office SBP, DBP and heart rate, daily monitoring of BP, biochemical blood test.Results and discussion. 51.4 % of patients took 3 antihypertensive drugs. 48.6 % took 4-6 antihypertensive drugs: among them, 4 drugs – 37.1 %, 9.1 % – took 5 drugs, and 2.4 % – 6 drugs. The degree of decrease in office BP among patients taking 3 or more antihypertensive drugs was 43.47 ± 0.65 mm Hg for systolic BP, and 20.33 ± 0.74 mm Hg for diastolic BP (p<0.001 for both values). 355 (31 %) patients failed to achieve the target level of office BP. They had true resistant hypertension. According to the Morisky – Green adherence questionnaire, on the background of the fixed triple combination of valsartan/amlodipine/hydrochlorothiazide, there was a significant improvement in adherence for all questions of the questionnaire. Patients began to forget to take pills significantly less, therapy became stable and regular, there were much fewer cases of stopping taking drugs due to deterioration of the patient’s condition after taking them, all 100 % of patients took antihypertensive drugs on the eve of the visit to the doctor, patients stopped canceling therapy due to their well-being at against the background of treatment, much fewer patients were bothered by the inconvenient regimen of taking drugs. Patient pill size was significant in only 11.4 % of patients at baseline and did not significantly change after 3 months of treatment with the fixed triple combination. But if patients had a choice, 60 % of them would choose the smaller pill. According to the determination of drugs in urine among 12 patients, we found that 25 % of patients (n=3) did not take drugs at all.Conclusions. Resistant arterial hypertension was found in 31 % of patients taking 3 or more antihypertensive drugs. When determining adherence to treatment based on the detection of drugs in urine, 25 % of patients with resistant arterial hypertension did not take the prescribed drugs at all, that is, they had pseudoresistance.

The first experience of using carboxyangiography in renal denervation in a patient with resistant arterial hypertension, chronic kidney disease and iodine contrast allergy

The first experience of using carboxyangiography in renal denervation in a patient with resistant arterial hypertension, chronic kidney disease and iodine contrast allergy

A Need for Improvement in the Definition of Resistant Arterial Hypertension.

With the medical and social importance of resistant arterial hypertension (HTN) in mind, we had three goals in this paper: to study the definitions of resistant HTN in the guidelines on the topic, to analyze them, and to suggest some improvements. We found (at least) eleven insufficiencies in the definition of resistant HTN: (1) different blood pressure (BP) values are used for diagnoses; (2) the number of BP measurements is not specified; (3) the time-frame for the definition is not obtained; (4) it fails to provide normal or target or controlled BP values; (5) secondary HTN is not currently defined as true resistant HTN, but as apparently treatment-resistant HTN; (6) the definition usually directly incorporates BP cut-offs for systolic BP (sBP) and diastolic BP (dBP) making the diagnosis temporary; (7) stress is not included in the exclusion strategy for resistant HTN; (8) there is potentially a need to introduce a category of recovered resistant HTN; (9) to what degree do healthy lifestyle measures have to be fulfilled to consider it as sufficient to change the diagnosis from "apparent treatment-resistant HTN" to the "resistant HTN"; (10) sBP values normal-for-the-age for 61 and 81 year old patients in some guidelines fulfill the criterion for resistant HTN; (11) it probably ought to read "In the absence of contraindications and compelling indications…" in the others. We believe that it is better to use the phrase "above the target BP" for the definition of (treatment) resistant HTN, because the whole story of resistant HTN is related to non-responders to antihypertensive treatment. Therefore, as we treat to target and not to normal values, it is appropriate to define resistant HTN as an insufficiency to reach the target BP values. Moreover, the definition of (treatment) resistant HTN should not be universal for every patient with HTN, but it should be age-related: (treatment) resistant HTN is elevated BP over the target/normal BP values. Using this modification, there will be no need to automatically change the definition of resistant HTN when we change the BP targets in the future.

Activity of matrix metalloproteinase type 9 and its relationship with calcification of the thoracic aorta in patients with resistant hypertension: cross-sectional comparative study

Background. The extracellular matrix of vessels is degraded under the influence of matrix metalloproteinases (MMPs). MMP type 9 is of particular interest in arterial hypertension (AH) since its activity is regulated by a tissue inhibitor of matrix metalloproteinase type 1 (TIMP1). The balance of their ratio can shift in either direction depending on the disease stage and provoke vascular wall calcification.
 Objective. This cross-sectional comparative study investigated the level of MMP9 and its type 1 tissue inhibitor and their relationship with the severity of thoracic aorta calcification in patients with resistant hypertension, depending on antihypertensive therapy effectiveness.
 Material and methods. The study included 92 patients with resistant hypertension. All patients underwent 24-hour blood (BP) pressure monitoring (ABPM), and had their index of the thoracic aorta (ТАС) and the plasma levels of MMP9 and TIMP1 assessed.
 Results. Patients were divided into groups based on whether they achieved the BP target level according to the results of ABPM: controlled (n=44) and uncontrolled (n=48) resistant AH. In the second group, most estimated parameters of ABPM were higher, and the variants of the daily BP profile for non-dipper and night-peaker systolic blood pressure (SBP) were more common than in the first group. In the second group, a more pronounced increase in TAC, TIMP1, and TIMP1/MMP9 levels was revealed. Evaluation of the relationship between the studied parameters revealed a positive relationship between TAC and age (r=0.683, p 0.00001), hypertension duration (r=0.610, p 0.00001) and a negative relationship with regular antihypertensive therapy duration (r=0.822, p 0.00001). ТАC was higher in individuals with higher values of SBP (r=0.513, р 0.00001), pulse BP (r=0.805, р 0.00001), rate of morning rise in BP (r=0.678, р 0.00001) and insufficient decrease in SBP at night (r=-0.822, р 0.00001). There was a positive correlation of moderate strength TAC with the level of low-density lipoproteins (r=0.490, p=0.0002), TIMP1 (r=0.344, p=0.005) and the TIMP1/MMP9 ratio (r=0.481, p 0.00001).
 Conclusion. In patients with resistant hypertension, an increase in the TAC was revealed, which has a statistically significant direct correlation with the value of pulse BP, the morning rise in BP, and an insufficient decrease in SBP at night. An imbalance in the TIMP1/MMP9 ratio, rather than an isolated increase in MMP9, can indicate the intensity of the formation and degradation of the extracellular matrix components in patients with resistant AH, which triggers the vascular wall calcification process.

Prognosis and risk factors for the adverse course of the disease in patients with arterial hypertension and its resistant form

Arterial hypertension (AH) is expected to contribute to approximately 13% of all deaths worldwide in the coming years. Objective — to perform retrospective analysis of the factors of the adverse course of the disease in patients with hypertension who were treated in a specialized department for secondary and pulmonary hypertension of the «NSC M. D. The Strazhesko Institute of Cardiology, Clinical and Regenerative Medicine » NAMS of Ukraine. Materials and methods. The analysis involved data from 524 patients who underwent the following standard examinations: measurement of office blood pressure (BP), 24h‑hours BP monitoring, echocardiography, electrocardiography. All patients received a questionnaire in five years after discharge from the hospital. It included questions about previous adverse events (myocardial infarction, stroke, unstable angina that required hospitalization, kidney failure, heart failure, newly diagnosed diabetes, hospitalization for another cardiovascular reason (aortic aneurysm, coronary artery bypass grafting, unstable angina pectoris, etc.). In case of death of a patient, relatives filled in the questionnaire. Adverse events or death were considered as a combined end point (CEP) of the study. Results. The following main factors, associated with the CEP occurrence in the examined patients, have been established: the age of the patient, systolic blood pressure level at discharge from the hospital, the level of pulse blood pressure (PBP) at discharge from the hospital, the presence of postinfarction cardiosclerosis, a history of stroke, increased size of the left atrium, reduced ejection fraction of the left ventricle, increased thickness of the interventricular septum, left ventricular myocardial mass index greater than 137 g/m2, disturbed daily profile of diastolic blood pressure (DBP), average daytime PBP level ≥ 64 mm Hg. The following risk factors were independent from other factors of CEP occurrence: the level of office PBP at discharge from the hospital ≥64 mmHg, reduced ejection fraction of the left ventricle ( 40%), thickening of the interventricular septum >1.2 cm, the mass index of the left ventricle > 137 g/m2, a decrease in BP during the night period<10%, average daytime BP during daily monitoring blood pressure ≥64 mmHg. Among the indicated factors, the following factors didn’t depend on the administered therapy: office PBP level ≥64 mmHg at discharge, left ventricular ejection fraction reduced by <40%, violation of the daily blood pressure profile (daily blood pressure index <10%) or average daily blood pressure higher than 64 mm Hg. Factors that significantly increased the CEP risk included systolic blood pressure level ≥160 mmHg (patients with resistant AH) and PBP ≥64 mmHg at discharge from the hospital; the CEP risk was increased by these factors was 84 and 66%, respectively. No significant effects on the frequency of occurrence of the combined end point were established for any group of antihypertensive drugs. Conclusions. Treatment‑resistant hypertension was a determining factor in the development of the combined end point. The degree of arterial pressure decrease was more significant for prognosis than the type of antihypertensive agent that lowered it.

THE ALGORITHM FOR THE TREATMENT OF PATIENTS WITH TREATMENT-RESISTANT HYPERTENSION AT THE OUTPATIENT STAGE

Every year in the world, arterial hypertension is the cause of death in about 9 million cases. Blood pressure control in patients has not yet reached the appropriate level, and the percentage of resistant arterial hypertension remains high. According to the definition of the American Heart Association, those patients whose condition requires taking four or more drugs to control blood pressure should be considered resistant to treatment. It should be understood that uncontrolled hypertension is not synonymous with RAH. The presence of RAH significantly increases the risk of cardiovascular complications, contributes to serious damage to target organs. Preliminary diagnosis of RAH definitely requires the exclusion of secondary hypertension, which is a rather heterogeneous group of diseases that is poorly recognized.
 The goal of the work. To acquaint general practice - family medicine doctors with the algorithm of treatment of patients with resistant arterial hypertension at the ambulatory stage.
 Treatment of patients with RAH should be carried out in stages, with increased therapy, using the most simplified scheme of taking drugs. Today, the combination of ACEI (perindopril), BCC (amlodipine) and diuretic (indapamide) is considered as the most optimal triple combination of antihypertensive drugs. Medicines containing three antihypertensive drugs in one tablet are offered precisely for RAH patients.
 Conclusions. The implementation of the algorithm for the examination of patients with RAH, recommendations for changing their lifestyle and a step-by-step therapy plan allow improving the control of blood pressure. Treatment of patients with RAH should include optimization of dosages and the appointment of rational combinations of antihypertensive drugs in order to enhance synergistic effects. Optimization of pharmacotherapy by prescribing drugs with fixed combinations can improve control of drug administration. The fixed combination of amlodipine-indapamide-perindopril may have the important advantage of increasing treatment adherence due to the principle of "one pill per day".

Effect of Renal Denervation on the Plasma Adiponectin Concentration in Patients with Resistant Hypertension

(1) Introduction: Adiponectin is synthetized by white adipose tissue and has anti-diabetic, anti-atherosclerotic, anti-thrombotic, anti-inflammatory, and cardioprotective properties. In patients with arterial hypertension, plasma concentration of adiponectin is lower than in healthy subjects. Renal denervation, i.e., percutaneous ablation of fibers from the sympathetic nervous system located in the wall of the renal arteries by radio frequency waves, is a method of resistant arterial hypertension treatment. (2) The aim of this single center, interventional, clinical study was to assess the effect of renal denervation on the plasma adiponectin concentration in patients with resistant arterial hypertension. (3) Materials and methods: 28 patients (13 women, 15 men) aged 54.4 ± 9.2 years with resistant hypertension who underwent renal denervation using Simplicity catheters (Medtronic, Inc., Northridge, CA, USA) were enrolled in the study. Plasma adiponectin concentration was determined using the Human Adiponectin ELISA Kit (Otsuka Pharmaceutical Co, Tokyo, Japan) before the renal denervation and 6 and 12 months after this procedure. (4) Results: Blood pressure (BP) values before renal denervation and 6 and 12 months after this procedure were as follows: systolic BP 190.4 ± 24.5, 160.8 ± 14.5, 155.7 ± 17.9 mmHg (p < 0.001) and diastolic BP 111.7 ± 18.9, 88.9 ± 8.3, 91.2 + 10.2 mmHg (p < 0.001), respectively. Body mass index (BMI) before renal denervation, 6 and 12 months after this procedure were 31.5 ± 4.2, 30.5 ± 4.4, 30.2 ± 4.0 kg/m2, (p = 0.057), respectively. Plasma adiponectin concentration before the renal denervation and 6 and 12 months after this procedure were 4.79 (3.95; 9.49), 7.58 (5.04; 9.51), 6.62 (4.57; 11.65) [µg/mL] (p = 0.007), respectively. (5) Conclusions: Plasma adiponectin concentration increases significantly after successful renal denervation in patients with resistant hypertension. Higher plasma adiponectin concentration may participate-beyond blood pressure reduction-in the cardiovascular benefits related to successful renal denervation; however' clinical consequences of these results need further investigations.

Resistant Hypertension Secondary to Primary Hyperaldosteronism

Resistant arterial hypertension is associated with multiple factors and secondary causes must be ruled out. One of the causes is primary hyperaldosteronism; the approach and its deflnitive diagnosis are described below

Uncontrolled and resistant arterial hypertension: prevalence, methods of modification of therapy

The management of patients with uncontrolled arterial hypertension in real clinical practice remains a difficult task, despite the impressive arsenal of antihypertensive drugs. In most cases, correction of medical therapy and lifestyle modification in this group of patients can achieve success in treatment, but in some cases, the target levels of blood pressure (AH) cannot be achieved.Aim. To assess the incidence of true resistant arterial hypertension in patients with hypertension, to identify the main causes of uncontrolled hypertension and to determine the main methods of modification of therapy.Materials and methods. The study included 70 patients with uncontrolled hypertension who received antihypertensive therapy previously. All patients underwent office measurement of blood pressure at the initial visit and after correction of therapy, 24-hour blood pressure monitoring (ABPM) was performed. Correction of therapy included the prescription of a standard three-component regimen «RAAS blocker + calcium antagonist + thiazide diuretic». In case of failure to achieve the target BP levels, the measurement of aldosterone/renin in the blood was carried out to exclude primary hyperaldosteronism (PHA). In all patients, the body mass index (BMI) was calculated, echocardiography was performed to determine the target organ damage, complete blood count, biochemical blood tests were performed (to detect existing kidney damage).Results. In 86% of patients, target BP levels were achieved through lifestyle modification (weight loss) and correction of previous therapy. In 24% of the study subjects, low adherence to therapy (non-compliance) due to polypharmacy was revealed, in connection with which patients were recommended to switch to fixed combinations of drugs, which made it possible to significantly reduce blood pressure below 140/90 mm Hg. according to the results of ABPM in all patients. In 8% of patients, amlodipine/lercanidipine was replaced with long-acting nifedipine, which also led to a decrease in blood pressure (−5,5 mm Hg mean blood pressure according to ABPM). In two cases, the diagnosis of PHA was established, the tumor form of this disease was excluded using computed tomography of the adrenal glands, and treatment with aldosterone antagonists was prescribed. In 10% of patients, the diagnosis of «Resistant arterial hypertension» was confirmed, spironolactone in low doses (25-50 mg), doxazosin 1 mg, moxonidine 0,4 mg, bisoprolol 5 mg were sequentially added to the treatment. Spironolactone and doxazosin showed similar efficacy (−7,1 mmHg and −6,9 mmHg in mean BP, respectively), moxonidine and bisoprolol were less effective (−4,8 and −5,2 mmHg,respectively). In two patients, the addition of spironolactone or doxazosin did not lead to the achievement of the target BP level, a loop diuretic (furosemide 40 mg) was added to the treatment.Conclusion. The incidence of resistant hypertension among patients in the study was 10%. All patients with uncontrolled hypertension, if it is impossible to achieve the target values of blood pressure, provided that the treatment is correctly prescribed, it is necessary to exclude symptomatic hypertension, in particular, PHA. In case of confirmation of true RAH, it is necessary to prescribe aldosterone antagonists (spironolactone) in small doses, and doxazosin is also acceptable.

The relationship of fibroblast growth factor 23 with calcification of the thoracic aorta according to the results of multislice computed tomography in patients with resistant arterial hypertension

Objective: to evaluate the incidence and severity of thoracic aortic calcification, the relationship with endothelial dysfunction and fibroblast growth factor in patients with resistant arterial hypertension.Materials and methods: the study involved 92 patients with resistant hypertension. Daily monitoring of blood pressure (ABPM) was performed, the functional state of the endothelium was assessed in a sample with reactive hyperemia, the calcium index (CI) of the thoracic aorta was determined using MSCT, and the serum level of FGF-23 was determined using enzyme immunoassay.Results: based on ABPM, patients were divided into groups 1st-controlled (n=44) and 2nd-uncontrolled (n=48) resistant AH. In the 2nd group, a more pronounced dysfunction of the endothelium was revealed in the sample with reactive hyperemia and changes in the velocity parameters of blood flow. FGF23 levels and CI were higher in individuals with uncontrolled resistant hypertension. According to the results of correlation-regression analysis, CI was associated with the value of pulse pressure (r=0.49, p=0.007), the duration of hypertension (r=0.68, p=0.04) and the duration of regular antihypertensive therapy (r = −0 .33, p=0.02). FGF- 23 was found to be associated with PA hemodynamic parameters: with Ved (r=0.42, p=0.003), PI (r=0.43, p=0.041) and RI (r=0.46, p=0.025), as well as with CI (r=0.76, p=0.006).Conclusion: patients with uncontrolled resistant hypertension showed a more pronounced decrease in brachial artery EVR and an increase in vascular resistance indices in the test with reactive hyperemia, which was statistically significantly associated with the level of FGF23. In patients with resistant hypertension, excessive calcification of the thoracic aorta was found according to the results of MSCT. Calcium index values are higher in patients with high pulse BP, longer duration of hypertension and high levels of FGF23.

Assessment of hemodynamic significance of renal artery stenoses in endovascular treatment of resistant vasorenal arterial hypertension

Objective. To determine the significance of renal artery stenosis according to different methods of assessing the functional significance of stenosis and to evaluate the safety and efficacy of stenting of unilateral renal artery stenosis after 6 months and 1 year according to office BP and ABPM.Materials and methods. The study included 44 patients with resistant arterial hypertension and renal artery stenosis (mean age 69 ± 11 years), while receiving multicomponent antihypertensive therapy, including diuretic. After assessing the degree of RA stenosis according to selective angiography and additional methods of assessing the functional significance of RA stenosis (iFR, Pd/Pa, translesional gradient and FFR) the patients underwent RA stenting. The safety of the procedure was assessed by creatinine and glomerular filtration rate dynamics (MDRD equation). The effectiveness of the procedure was study according to office blood pressure (BP) and ambulatory BP monitoring (ABPM).Results. According to the results of angiography, the patients were divided into two groups: group A – patients with subtotal PA stenosis (&gt; 90%) and group B – patients with moderate stenosis (60-90%), who underwent additional assessment of the functional significance of stenosis. The immediate angiographic result in both groups was optimal (the degree of residual stenosis was less than 5%). In group B, after stent implantation in the PA, there was a decrease of the translesional gradient by 38 ± 10 mm Hg (p &lt; 0,0001), FFR &gt; 0,8(p &lt; 0.0001). iFR &gt; 0.89, Pd/Pa&gt;0.9 (p = 0,093). In both groups, there was a significantly significant reduction in arterial blood pressure at distant times, according to clinical BP measurement and ABPM.Conclusion. The measurement of such parameters as translesional gradient and fractional reserve is the most reliable in assessing the hemodynamic significance of PA stenosis in comparison with iFR and Pd/Pa measurements in patients with moderate PA stenosis. PA stenting in patients with uncontrolled resistant AH and severe renal artery lesions, as well as moderate stenosis confirmed by additional methods of stenosis functional significance assessment is reasonable to consider in order to enhance the antihypertensive effect.

Optimization of blood pressure control in patients with resistant arterial hypertension and visceral obesity

Aim. To evaluate the course of resistant arterial hypertension in patients with visceral obesity, to identify predictors of unsatisfactory shot-term and long-term treatment outcomes, to optimize therapy and improve adherence to treatment.&#x0D; Materials and methods. A total number of 90 individuals with a history of refractory or resistant arterial hypertension and visceral obesity were a subject of intensive study. The prospective analysis group consisted of 30 patients with an individualized management plan each, whereas the retrospective group of real clinical practice included 60 participants. At baseline, all patients were taking antihypertensives like ACE inhibitors or angiotensin II receptor blockers (ARBs)/angiotensin-converting enzyme inhibitors, calcium channel blockers (CCBs), and a diuretic. After the initial examination, therapy was individually optimized for each patient in accordance with current clinical guidelines. Most patients in the retrospective group received ARBs valsartan or losartan, CCBs amlodipine, the diuretics indapamide and torasemide, the -blockers bisoprolol and metoprolol, the 2-agonist moxonidine, and the mineralocorticoid receptor antagonist spironolactone. Patients in the prospective group were prescribed ARBs telmisartan and azilsartan, the CCB lercanidipine, thiazide and thiazide-like diuretics indapamide and chlorthalidone, the -blockers nebivolol and carvedilol, the 1-blocker doxazosin, and spironolactone. A re-examination was performed 2 months later. Subsequently, regular communication was maintained with participants of the prospective group during 8 months using a messenger. Communication with patients of the retrospective group was not maintained. All the patients were then asked to self-report their health status by conducting a telephone survey.&#x0D; Results. After 2 months, according to the data of the follow-up, in the retrospective group the target values of mean daily SBP and DBP were observed in 35 and 36.7% of patients, though the statistics among the patients in the prospective group were 66.7 and 60%, respectively. After 10 months, according to the results of the interviews, the target values of SBP and DBP were observed in 10 and 18.3% of patients, though the statistics among the patients in the prospective group were 93.3 and 96.7%, respectively. In the retrospective group, 78.3% of patients changed the previously selected therapy, in the prospective group this figure was only 20%. In the retrospective group, anthropometric data did not change, while in the prospective group, weight and waist circumference significantly decreased (p0.05).&#x0D; Conclusion. Maintaining regular contact with patients and a well-rounded treatment strategy with individualized choice and dosage of medications with an emphasis on modern metabolically neutral drugs with a prolonged duration of action led to better BP control, increased adherence to therapy and indicated significant weight loss among the patients from the prospective group.

745 INTERDISCIPLINARY EVALUATION IN RESISTANT ARTERIAL HYPERTENSION

Abstract Background Arterial hypertension is a complex and in most cases multifactorial pathology. Despite the numerous pharmacological treatments available, it is estimated that in Europe only 25%-39% of hypertensive patients achieve adequate blood pressure (BP) control. Renal arteries denervation (RDN) is an additional therapeutic weapon, complementary to Optimal Medical Therapy (OMT) in patients with resistant or refractory primary (or essential) arterial hypertension. In order to improve patients management and select those who are eligible for renal denervation, our Center has established the Interdisciplinary Group for the Treatment of Resistant Arterial Hypertension (G.I.T.I.A.R.), including Cardiologists, Nephrologists, Internists and Geriatricians. Methods From January 2018 to July 2022 the G.I.T.I.A.R. held twelve meetings evaluating 62 patients with resistant or refractory forms of arterial hypertension, contraindications or intolerance to antihypertensive drugs, suspected secondary or pseudoresistant forms (i.e. linked to poor patient compliance, drugs and/or inadequate dosages, concomitant intake of substances with hypertensive effect, incorrect measurements). For each of them, medical therapy was optimized and the need for second level diagnostic tests, multi-specialist follow-up and RDN candidacy were assessed. After three, six, twelve months and then annually following RDN, the patients underwent clinical and multi-specialist evaluation (where deemed appropriate), blood tests monitoring and 24-hour ambulatory blood pressure monitoring (ABPM). Results Of the 62 patients evaluated by the G.I.T.I.A.R., 64.5% (n=40) were male. The mean age at the time of evaluation was 64 years (range 18-87). After the first collegial discussion, 46.8% (n=29) have been declared eligible for RDN, while 53.2% (n=33) of the patients was initially rejected: 39.4% of these (n=13) for suspected or ascertained secondary hypertension, 12.1% (n=4) for the possibility of further optimization of medical therapy, 48.5% (n=16) for the presence of inclusion or exclusion criteria of ongoing studies design. Among the excluded patients, six presented moderate renal artery stenosis on non-invasive imaging: in two patients (33.3%) the stenosis turned out to be hemodynamically significant on angiographic and functional evaluation (Pd/Pa measurement), so renal angioplasty was performed; RDN was performed in the remaining 66.7% (n=4), in which a hemodynamic significance of the stenosis was excluded. Of the subgroup who had optimized medical therapy, one patient (25%) was subsequently referred to RDN for failure of all pharmacological strategies, while 3 of 4 (75%) achieved adequate BP control. Conclusions Resistant arterial hypertension is associated with an increased risk of development and progression of cardiovascular and renal diseases, with a significant impact on mortality and morbidity. Renal denervation has proved to be an effective and safe therapeutic strategy, complementary to OMT, whose selection of the ideal patient actually represents one of the greatest challenges. The integrated multidisciplinary approach improves the management of the hypertensive patient, the individualization of therapy and allows the identification of subjects who may benefit from RDN.

Arterijska hipertenzija i bubrežna bolest - neočekivana komplikacija

Arterial hypertension and chronic kidney disease are mutually interconnected. Uncontrolled arterial hypertension along with diabetes is one of the two most common causes of end-stage chronic kidney disease. On the other hand, chronic kidney disease, as well as renal artery stenosis, results in the development of arterial hypertension. Hypertensive crisis with target-organ damage, also known as a hypertensive emergency, is a serious arterial hypertension complication which is however becoming less frequent. It requires urgent parenteral antihypertensive treatment adjusted to the values of arterial hypertension and accompanying clinical signs. Damage can manifest on numerous organ systems primarily eyes, brain, cardiovascular system, and the kidneys. This is a case report of a patient who presented with hypertensive crisis and kidney damage and was eventually diagnosed with abdominal aortic dissection expanding into the renal arteries, but without typical clinical presentation of stabbing pain. MSCT aortography, despite the risk of progression of renal damage due to the effect of contrast agent, allowed us to set definitive diagnosis and clarify the aetiology of kidney damage and resistant arterial hypertension.

Analysis of lifestyle modifications and antihypertensive therapy in patients with arterial hypertension and chronic kidney disease (data from the national registry)

The aim is to study the characteristics and quality of drug therapy and recommendations for lifestyle changes in patients with chronic kidney disease and arterial hypertension and, separately, chronic kidney disease and resistant arterial hypertension, observed in primary health care.Materials and methods. The study was carried out on the basis of the AH registry data (N = 43133; 2005-2019 years). Glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula; renal structure and albuminuria were not evaluated. The analysis was performed using the SPSS software (version 22; SPSS Inc).Results. Less than half of all patients reached the target SBP values. ACE inhibitors/ARBs were not prescribed as first-line antihypertensive therapy in 18% of patients with stage 3 CKD. ACE inhibitors were more often prescribed to men than women (70,6% and 66,5%), and ARBs (11,9% and 15,6%). The frequency of prescribing ACE inhibitors, thiazide and thiazide-like diuretics remained practically unchanged at GFR ≥ 60 and 60 ≥ GFR &lt; 30 ml/min/1,73m2, while the frequency of prescribing ARBs, CCBs, loop diuretics increased with a decrease in glomerular filtration rate. Approximately 60% of patients with hypertension were given advice on nutrition and normalization of body weight (among patients with obesity), about 50% — advice on physical activity and ~50% of smokers received advice on smoking cessation. In patients with hypertension and GFR below 60 ml/min/1,73m2, primary care physicians gave advice on lifestyle changes more often than patients with higher GFR. In men with hypertension and 3 stage CKD the incidence of coronary artery disease (2 times), CHF (1,5 times), the incidence of myocardial infarction in history (3,4 times), the incidence of stroke in history (1,9 times) higher than in women. The frequency of the presence of probable resistant hypertension increased up to 23,9% with a decrease of eGFR among patients with uncontrolled hypertension and up to 11% with controlled.Conclusion. For patients with hypertension and CKD, it is necessary to achieve target values of blood pressure, conduct drug therapy aimed at blocking the RAAS (ACE inhibitors /ARBs), select drugs from the CCB group and diuretics as second and third line therapy. In patients with resistant hypertension the addition mineralocorticoid receptor antagonists is necessary.

Uncontrolled hypertension and obstructive sleep apnea: integrated treatment approach

The main goal in the arterial hypertension (AH) management is the target blood pressure (BP) achievement, as it leads to the cardiovascular risk reduction. At the same time, proper BP is achieved less than in 50% of all cases. In addition, there are two types of truly uncontrolled AH in population, such as resistant (RAH) and refractory (RFH) AH. Recent research suggests that RAH may be associated with changes in the renin-angiotensin-aldosterone system, while RFH appears to be more closely associated with sympathetic hyperactivation. These pathophysiological mechanisms are also active in patients with obstructive sleep apnea (OSA). Therefore, the prevalence of OSA in patients with RAH and RFH is very high, and treatment with continuous positive airway pressure (PAP-therapy) can reduce BP levels in such patients. The latter allows us to consider PAP-therapy as an additional method for the target BP achievement in patients with uncontrolled AH and OSA.