Vol 17, No 3 (2020)


Clinical practice guidelines on the diagnosis and treatment of patients with arterial hypertension and chronic obstructive pulmonary disease

Chazova I.E., Nevzorova V.A., Ambatiello L.G., Brodskaia T.A., Oshchepkova E.V., Belevskii A.S., Zhernakova J.V., Aisanov Z.R., Ovcharenko S.I., Chuchalin A.G.


One of the most common comorbid condition in people over 40 years old is: arterial hypertension (AH) and chronic obstructive pulmonary disease (COPD). The frequency of AH in patients with COPD varies from 6.8 to 76.3%, in average 34.3%. COPD is detected in every fourth patient with hypertension in the age group of 25–64 years. The current trend towards an increase in life expectancy and therefore growing pool of elder cohort, will lead to a higher number of patients with comorbid disorders. Diagnosis and treatment of AH and COPD are determined by current clinical recommendations for both nosologies, however, a number of mutual pathophysiological mechanisms lead to a more severe course of these diseases with frequent exacerbations. The choice of antihypertensive therapy in patients with AH in combination with COPD should be given to drugs that can provide an adequate decrease in blood pressure in hypoxic conditions, especially at night and early morning hours, that have prolonged effect or could be prescribed in the evening, and to those that don’t worsen bronchial obstruction or exacerbate hypoxia. Patients with AH and COPD should be given recommendations on lifestyle changes, especially smoking cessation. As initial therapy calcium channel blockers, angiotensin receptor blockers or angiotensin-converting enzyme inhibitors should be considered. Calcium channel blockers/renin-angiotensin system blockers should be considered as the first line for combination therapy. Thiazide, thiazide-like diuretics or b1-selective adrenergic blockers could be prescribed in case of insufficient antihypertensive response or depending on different clinical scenarios. Bronchodilators are the baseline therapy in COPD with concomitant AH. According to modern concepts, prescription of combination therapy with different mechanisms of action is the most proven and justified approach, which leads to a decrease in the frequency of exacerbations of COPD and amelioration of the symptoms. The choice of bronchodilator in the case of a COPD and AH combination, should take into account the proven long-term safety regarding the risk of cardiovascular complications. Tiotropium bromide as the monotherapy, including as a liquid inhaler and aclidinium/formoterol, tiotropium/oladeterol as combination therapy showed cardiovascular safety in the long-term studies. The escalation of COPD therapy with the need of inhaled steroids requires careful monitoring of blood pressure and, possibly, a revision of antihypertensive treatment leading to its escalation as well. COPD has many phenotypes requiring different medications, eg.: roflumilast, theophylline, macrolides and mucoactive drugs, that could also require tighter blood pressure control on patients with COPD and AH.

Systemic Hypertension. 2020;17(3):7-34
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Expert opinion

Russian Medical Society for Arterial Hypertension Expert Consensus: Hypertension and COVID-19

Chazova I.E., Blinova N.V., Nevzorova V.A., Zhernakova J.V., Savenkov M.P., Oshchepkova E.V., Ostroumova O.D., Kisliak O.A., Boytsov S.A.


The novel coronavirus infection (COVID-19) caused by the b-coronavirus SARS-CoV-2, and leads to acute respiratory distress-syndrome, has affected more than nineteen million people worldwide, resulting in 0.7 million deaths as of August 2020. The fact that the virus uses angiotensin-converting enzyme 2 as a receptor for entering the target cell, and the high prevalence of hypertension and other cardiovascular diseases among patients with COVID-19, have caused serious discussions on the management of such patients. This consensus of experts from the Russian Medical Society for Arterial Hypertension analyzed the existing data on the relationship between COVID-19 and hypertension, the pathophysiological aspects of the penetration of the virus into target cells and the use of renin-angiotensin-aldosterone system inhibitors in patients with hypertension and COVID-19.

Systemic Hypertension. 2020;17(3):35-41
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Original Article

Speckle-tracking echocardiography in 3D mode in assessing the deformation of the myocardium and identifying subclinical cardiotoxicity during chemotherapy in breast cancer patients with arterial hypertension

Avalyan A.A., Saidova M.A., Oshchepkova E.V., Chazova I.E.


Aim. To study the possibilities of speckle-tracking echocardiography (STE) in 3D mode in assessing the strain of the myocardium and identifying subclinical cardiotoxicity during anthracycline-containing chemotherapy in breast cancer patients with arterial hypertension.

Materials and methods. The study included 47 patients with triple negative breast cancer (BC) with AH and normotension. All patients underwent transthoracic echocardiography with an assessment of the left ventricular (LV) ejection fraction, also used STE in three-dimensional mode with an assessment of global longitudinal (GLS), circular (GCS), radial (GRS) strain and a new strain parameter – strain area (GAS).

Results. In patients with BC for a more accurate assessment of LV systolic function, it is advisable to use 3D echocardiography. In BC patients with AH, the initial parameters of LV strain were statistically significantly worse than in patients with normotension and further deterioration was observed after chemotherapy. To determine the sensitivity and specificity of the strain parameters from the 3D-STE data, an ROC analysis was performed. The most diagnostically significant parameter of strain, as a marker of cardiotoxicity, was the global area strain (GAS), which with a cut-off value ≥-14.0% showed a sensitivity equal to 81.5% and a specificity of 73.3%, but the value this parameter of LV deformation requires further study.

Conclusion. In BC patients with AH and normotension it is advisable to use the STE in 3D mode to analyze the strain and systolic function of the LV during antitumor treatment. The method is promising for identifying subclinical cardiotoxicity, but further research is needed to develop diagnostic criteria.

Systemic Hypertension. 2020;17(3):42-47
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Contrast-associated acute kidney injury in patients with arterial hypertension and stable coronary artery disease

Mironova O.I., Fomin V.V.


Relevance. The combination of stable coronary artery disease (CAD) and arterial hypertension (AH) is one of the most common seen by cardiologists. The administration of contrast media might increase the risk of development of acute kidney injury, especially in patients with comorbidities. The influence of iodine contrast media administration on the risk of development of contrast-associated acute kidney injury (CA-AKI) in patients with stable CAD and AH was studied in our work.

Materials and methods. 863 patients with stable CAD and AH and indications for interventions requiring intraarterial administration of contrast media were included in the prospective open observational cohort study (ClinicalTrials.gov ID NCT04014153). CA-AKI was defined according to KDIGO criteria as the elevation of serum creatinine 25% and more above baseline or 0.5 mg/dl (44 mkmol/l) and more in 48 hours after intraarterial administration of contrast media. The primary endpoint was the development of CA-AKI.

Results. Diabetes mellitus, obesity and hyperuricemia were not statistically significant risk factors of CA-AKI development according to the contingency tables analyses, unlike proteinuria. A logistic regression model was built (area under the curve 0.7638, p<0.0001, 95% confidence interval 0.713–0.815) and included the following risk factors: age, weight, body mass index, female gender, heart failure, proteinuria, AH, anemia, baseline creatinine. Proteinuria, baseline creatinine and contrast volume were statistically significant ones.

Conclusion. The rate of CA-AKI was 12.6%. Proteinuria, baseline creatinine and contrast volume were statistically significant risk factors of CA-AKI in logistic regression model.

Key words: contrast-induced acute kidney injury, contrast-induced nephropathy, contrast-associated acute kidney injury, coronary artery disease, percutaneous coronary intervention, arterial hypertension, stable coronary artery disease, prognosis.

Systemic Hypertension. 2020;17(3):48-52
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Parameters of acute vasoreactivity testing after balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension

Yarovoy S.Y., Chazova I.E., Matchin Y.G., Danilov N.M.


Aim. To study the effect of balloon pulmonary angioplasty (BPA) on the changes of pulmonary artery pressure, cardiac output and structural parameters of pulmonary arteries after acute vasoreactivity testing (AVT) in inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH).

Materials and methods. The prospective study included 22 patients with inoperable CTEPH. 11 patients underwent intravascular ultrasound (IVUS) of the pulmonary arteries. The assessment of clinical and hemodynamic parameters, vasoreactivity, structural parameters of the pulmonary arteries according to IVUS data was performed at 2 visits – before the first BPA and after a series of BPA.

Results. The patients underwent 2.3±1.4 stages of BPA. The follow up was 160 (85; 248) days. Positive changes after a series of BPA were revealed in clinical (functional class, distance in the 6-minute walk test, level of brain natriuretic peptide) and hemodynamic (systolic and mean pulmonary artery pressure, right atrium pressure, etc.) parameters. The results of the AVT after BPA demonstrated a decrease in the portion of “non-responders” from 63.6 to 55.5%, and a group of “responders” (16.7%) has appeared. According to IVUS before and after AVT, the response to iloprost administration was observed basically in branches of subsegmental pulmonary arteries and initially corresponded to the process of vasodilation. However, after a series of BPA there was noted a paradoxical reaction in the middle section after the AVT – a decrease in the vessel lumen and an increase in the thickness and area of the vessel wall. This effect is probably associated with the response to the test at the level of the microvasculature, as in pulmonary arterial hypertension before the onset of its pronounced structural changes. The data obtained confirm the reverse remodeling of the pulmonary vessels and the restoration of vasoreactivity after a series of BPA.

Conclusion. BPA improves clinical and hemodynamic parameters, as well as pulmonary vasoreactivity, in inoperable patients with CTEPH. AVT may be included in the recommendations for the examination of patients with CTEPH to assess the effectiveness of BPA and determine the disease prognosis.

Systemic Hypertension. 2020;17(3):53-58
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Implementation of the organoprotective properties of fixed combinations of valsartan, amlodipine and hydrochlorothiazide (Vamloset® and Co-Vamloset) in patients with grade 2 and 3 hypertension in the Russian clinical study VICTORY II

Chazova I.E., Martynyuk T.V., Rodnenkov O.V., Gorieva S.B., Rogoza A.N., Arkhipov M.V., Grinshtein Y.I., Ostroumova O.D., Galiavich A.S., Rotar’ O.P., Khaisheva L.A., Kameneva T.R.


Aim. Assessment of Vamloset® and Co-Vamloset effects on blood pressure target levels and indicators associated with organ protection: albuminuria; elasticity of arteries and central aortic pressure (CAP); endothelial function; tumor necrosis factor-a, interleukin (IL) IL-6 and IL-10, vascular cell adhesion molecule 1 and vascular endothelial growth factor (VEGF-A).

Materials and methods. The Russian multicenter open-label prospective clinical study VICTORY II which was conducted in 8 clinical centers included 103 patients >18 years with grade 2–3 essential arterial hypertension (AH), who were previously untreated – office systolic blood pressure (SBP) ≥160 mm Hg and/or office diastolic blood pressure (DBP) ≥100 mm Hg – or have not reached the target office blood pressure with mono- or dual therapy. The active phase of the study included 100 patients; the per-protocol (PP) population – 80 patients completing the study without major protocol deviations. Patients were not randomized. The target office BP for patients without diabetes were: SBP≤139 mm Hg, DBP≤89 mm Hg; for patients with diabetes: SBP≤139 mm Hg, DBP≤84 mm Hg. All patients with grade 2 hypertension (group 1) were administrated Vamloset® (amlodipine/valsartan, 5/80 mg), with grade 3 hypertension – Vamloset® (amlodipin/valsartan, 5/160 mg). Up-titration of the dose of amlodipine/valsartan to 5/160 mg and 10/160 mg, the administration of Co-Vamloset (amlodipine/valsartan/hydrochlorothiazide) in doses of 10/160/12.5 mg, 10/160/25 mg (LLC «KRKA-RUS») was carried out every 4 weeks according to the prescribed schemes. In the total group, the effect of studied therapy on the level of albumin in the urine was assessed. Before starting treatment and after 16 weeks of treatment, 40 patients in the subgroup with additional examinations underwent daily monitoring of blood pressure, assessment of pulse wave velocity and augmentation index; CAP; levels of tumor necrosis factor-á, IL-6 and IL-10, vascular cell adhesion molecule 1and VEGF-A.

Results. The active phase of the study included 100 patients aged 59.5±10.9 years (59% of women) with a duration of AH 83.4±8.4 months. 83% of patients received prior antihypertensive therapy by the time of enrollment in the study. The treatment duration for all patients was 15.9 weeks. After 16 weeks, therapy with Vamloset® and Co-Vamloset provided an optimal decrease in BP: 90% of patients with grade 2–3 AH in the PP population reached the target level of office BP, the mean change in SBP / DBP was -32.2/-16.0 mm Hg. According to the data of daily monitoring of BP in the subgroup with additional examinations, the target levels of average daily SBP/DBP were reached in 52.9/67.6% of patients, respectively. Along with reliable control of blood pressure, additional organ protection with studied antihypertensive drugs after 16 weeks of therapy was shown by assessment data: albuminuria – in 58.8% of patients with an initially elevated level of albuminuria (n=17), a positive effect of the studied therapy on the level of albumin in the urine was determined, augmentation index – improvement in 57.1% of patients in the study group, CAP – improvement in 73% of patients in the study group; positive dynamics of endothelial damage markers (IL-6, IL-10, VEGF-A) was achieved. The data on the good tolerability of AHT corresponded to the previously established safety profile of these drugs.

Conclusion. In the VICTORY II clinical study in patients with grade 2–3 hypertension, along with high antihypertensive efficacy, a spectrum of organoprotective effects of Vamloset® and Co-Vamloset on aortic stiffness with improved augmentation index and CAP, markers of endothelial damage (IL-6, IL-10, VEGF-A), the severity of albuminuria was shown.

Systemic Hypertension. 2020;17(3):59-70
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