Vol 85, No 9 (2013)

Aim. To study the features of the impact of the extreme climate and weather factors of an arid area, which cause exacerbations of circulatory system diseases (CSD). Materials and methods. The authors have studied 32,339 visits for emergency medical care (EMC) because of exacerbations of CSD (coronary heart disease, angina pectoris (n = 29,932), myocardial infarction (n = 306), hypertensive crises (n = 2,101) and their events) when the Afghan wind forms in winter and spring and on heat discomfort days in summer. Meteological parameters, synoptic patterns, partial oxygen density (AOD) in the atmosphere, atmospheric electric potential gradient, and human heat sensation (equivalent and effective air temperatures (EEAT)) were estimated using the generally accepted three-hour gradations. Results. In the formation of the Afghan wind (24-48 hours before its surge, i.e. in the prodromal phase), the atmospheric electric potential gradient increased by 4-10 times. Atmospheric pressure fell by 15-20 mbar; air temperature rose by 10-15°C, AOD dropped by 15-25 g/m3 - a hypoxic type of weather formed. In the surge phase, the hypoxic type drastically changed to the spastic one - there was an increase in atmospheric pressure and a decrease in air temperature (by 12-19°C), which gave rise to circulatory hypoxia due to vascular spasm. The average daylight air temperature changed from +31.1 to +42.2°C, amounting to +36.6±1.2°С; EEAT was in the gradation of heat (27-30°C) and very heat (32°C or higher), AOD decreased (248.6±1.3 g/m3), a hyperthermia-and-hypoxia type of weather was observed. The rates of EMC visits by the population for CSD exacerbations were strongly correlated with the formation of the Afghan wind (Spearman rank correlation 0.82). In the prodromal and Afghan wind surge phases, the number of exacerbations of CSD increased by an average of 2.2-3.6 times. Analysis of annual patient visits by hours during a day showed that their first rise was seen at 9.00 to 12.00 and the second (more substantial) one at 18.00 to 21.00 (p < 0.05). However, in summer, the patient visit rates increased at 15.00 local legal time when there was human thermal sensation at the gradation of heat under hyperthermal hypoxia more frequently in people older than 70 years. Conclusion. The rates of EMC visits by patients for CSD exacerbations increased in the formation of the Afghan wind and in summer during significant heat discomfort; hypoxia (external weather and internal circulatory hypoxia) is a major pathophysiological factor in these situations.

Aim. To evaluate the efficiency and safety of outpatient physical exercises (PE), calculated using ergospirometry (ESM) in patients in the early periods after elective percutaneous coronary interventions (PCI) during incomplete coronary bed revascularization. Subjects and methods. Three hundred and eighty-three patients were screened. The trial enrolled the patients after elective PCI in its early periods (3 to 14 days) who had signed an informed consent document to participate in the investigation and who could perform themselves PE at home or visit the medical center. Patients with angioplasty complications (myocardial infarction, severe hematomas, major bleeding, etc.) who had standard contraindications to exercise testing and PE were excluded. The patients included in the trial (n = 50) were divided into 2 groups: 1) 21 patients who had undergone incomplete revascularization; 2) 29 patients who had complete revascularization. The authors estimated exercise endurance by ergospirometry before the investigation, 8 weeks after a course of exercises, and following 6 months and assessed quality of life (QL) using the SF-36 questionnaire. A physical rehabilitation program was elaborated for all the patients according to exercise test results. During the trial, all the patients were allocated to groups of home and clinic exercises using exercise bikes. Medical control of the patients who were exercising at home was made by their telephone conversation, control visits to the medical center at least once monthly, and their concurrently keeping an exercise diary in which each training (duration, intensity), health status, and blood pressure were recorded. The patients could consult their physician at any time if required. Results. In the incomplete and complete revascularization groups, VO2 max increased by 6 and 15%, respectively. Following 6 months, no additional increment in VO2 max was seen in the study groups. According to SF-36 data, QL improved in patients in both groups after 8 weeks and remained at the same level after 6 months. Conclusion. An early time course of exercises only in combination with regular medical control has a positive impact on exercise tolerance and QL and preserves its efficiency for at least 6 months regardless of the degree of revascularization.

Aim. To collect information on the efficiency and safety of a fixed-dose combination of amlodipine/valsartan in patients who failed to achieve blood pressure (BP) control in the use of the combination of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) and a thiazide/thiazide-like diuretic. Subjects and methods. During routine clinical practice, the 12-week observation program covered 8594 hypertensive patients receiving a fixed-dose combination of amlodipine/valsartan 5/160, 10/160 mg (exforge, Novartis Pharma) with/without a diuretic. The inclusion criteria were 18 years of age or older; systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg) at the first visit; failure to achieve BP (≥140/90 mm Hg) control in the use of the combination of an ACE inhibitor or an ARB and a thiazide/thiazide-like diuretic; a patient's consent to participate in the program. The exclusion criteria were, besides the contraindications given in the drug use instruction, absent. Amlodipine/valsartan 5/160 or 10/160 mg were used after the previous ineffective therapy was discontinued. The patients visited their physician's office every 4 weeks. Results. The patients' baseline BP was 169.3/99.9 mm Hg. The risk of cardiovascular events was assessed as high in 38% of the patients and as very high in 43.1%. The previous therapy included thiazide or thiazide-like diuretics (92%), an ACE inhibitor (78.5%), an ARB (23.2%), Β-adrenoblockers (38.6%), calcium antagonists (23.1%), and other medications (25.5%). In the entire group, BP decreased from 169.3±15.6/99.9±9.3 to 129.1±9.1/80.3±6.4 mm Hg at the fourth visit. BP reductions at 12 weeks were 40.1±14.9/19.6±9.5 mm Hg. The therapy was effective in different treatment subgroups. At baseline, the majority of patients had grades 2 (53.1%) and 3 (35.4%) hypertension. At 12 weeks, 74% of the patients were found to have normal or high normal BP. Grade 3 hypertension was preserved only in 0.2% of the patients by the end of the program. BP goals were achieved in 79.5% of the patients. The therapy was well tolerated by the patients. Adverse reactions were observed in 3.1% of the patients and required treatment discontinuation in 0.5%. The most common side effect was peripheral edemas (1.4%). Conclusion. In the observation program AESCULAP using the fixed-dose combination of amlodipine/valsartan as different dosage regimens (5/160 and 10/160 mg) and/or a diuretic, there was a marked antihypertensive effect in different subgroups of patients with previously uncontrolled hypertension and the BP goals being achieved in 79.5% of cases. Most patients tolerated amlodipine/valsartan well and showed high compliance with the prescribed therapy. The rate of side effects in the AECULAP program was not greater than that (3.1%) in the earlier trials.

Aim. To assess an association of uric acid level with preclinical target organ damage in patients with hypertensive disease (HD). Subjects and methods. The trial enrolled 100 patients (63 men and 37 women) with Stage I-II HD at moderate and high risk for cardiovascular events (CVEs). The mean age of the patients was 44.9±1.3 years. Their medical history showed that the duration of hypertension averaged 4.4±0.3 years. The average daily level of systolic blood pressure (BP) was 138.1±1.4 mm Hg and that of diastolic BP was 84.3±1.1 mm Hg. Results. The entire patient group showed a positive correlation between C-reactive protein (CRP) and serum uric acid (SUA) (r = 0.27; p < 0.01), suggesting that the nonspecific inflammatory processes were associated with uric acid levels in patients with HD. An intragroup analysis also revealed a relationship between CRP and SUA levels in the hypertensive patients at high risk for CVEs (r = 0.43; p = 0.01); this relationship was not found in those at their low risk. The hypertensive patients were ascertained to have elevated CRP levels and microalbuminuria, hyperuricosuria, and glomerular hyperfiltration when they had a SUA level >319 µmol/l. Conclusion. It can be assumed that the SUA level >319 µmol/l triggers the activation of nonspecific inflammatory processes, which in turn affects renal microvessels.

Aim. To evaluate the impact of combination antihypertensive therapy with lisinopril + amlodipine (Еkvator) on endothelial dysfunction in patients with hypertension and concurrent type 2 diabetes mellitus (T2DM). Subjects and methods. The trial enrolled 30 patients aged 40 to 65 years with Stages II-III hypertension concurrent with T2DM. All the patients received combination antihypertensive therapy with lisinopril + amlodipine (ekvator) for 12 weeks. Endothelial function was studied from serum and urinary NO and endothelin-1 concentrations and occlusion test results. 24-hour blood pressure (BP) monitoring and echocardiography were performed; arterial elastic properties and renal function were investigated. Results. After 12-week therapy, 93.3% of the patients achieved BP goals. Endothelial function was improved in hypertensive patients with T2DM: there were increases in both serum and urinary NO production (by 53.5 and 57.1%, respectively) and decreases in serum and urinary endothelin-1 secretion (by 27.7 and 69.6%, respectively). The number of patients with normal microcirculation increased from 13.3 to 73.3% (p<0.001). There was significant improvement in 24-hour AP monitoring readings and reductions in the left ventricular mass index by 10.7% and microalbuminuria by 27.7%; the number of patients with increased pulse wave velocity along the elastic arteries declined by 30%. Conclusion. Twelve-week treatment with the combined antihypertensive medication ekvator is highly effective and safe for recovering endothelial function and improving the state of target organs in hypertensive patients with T2DM.

Aim. To study the effect of eprosartan, an angiotensin II type 1 (AT1) receptor blocker, with sympatholytic activity on the hemostatic system in patients with chronic kidney disease (CKD) associated with hereditary thrombophilia. Subjects and methods. The 12-week open-label uncontrolled trial included 31 patients with Stages I-II CKD: 15 patients with chronic glomerulonephritis and 16 with diabetic nephropathy burdening types 1 and 2 diabetes mellitus (DM) in 10 and 6 cases, respectively. In all the patients, CKD was associated with one of the heterozygous forms of thrombophilia: the polymorphic methylenetetrahydrofolate reductase gene variant C677T was found in 18 patients; the polymorphic coagulation factor V gene variant G1691A was in 9; and the polymorphic coagulation factor II gene variant G20210A in 4. Along with the thorough examination accepted in nephrology and endocrinology clinics, investigations of vascular-thrombocytic and secondary hemostasis and the anticoagulant and fibrinolytic systems were made before and after treatment. Results. Eprosartan therapy caused positive changes in the indicators of vascular-thrombocytic (diminished platelet aggregation, reduced surplus of von Willebrand factor and endothelin-1) and secondary (decreased coagulation factor VII activity, longer activated partial thromboplastin time) hemostasis and the anticoagulant (reduced antithrombin III deficiency) and fibrinolytic (elevated blood plasminogen concentrations) systems. Conclusion. The pleiotropic effects of eprosartan may be used to correct hypercoagulability syndrome in patients with CKD associated with hereditary thrombophilia.

The diagnosis of neurogenic and psychogenic dysurias is the most difficult and controversial problem of modern urology, the solution of which requires a differentiated approach based on the comparison of neurological, psychic, and urologic symptoms. The basis for their diagnostic search is the method of substitution of found symptoms in the schemes of known urologic, neurological diseases and psychopathological states in the direction from the general to the particular, i.e. by the method of deductive reasoning. The results of diagnostic tests and pharmacological analysis only clarify the details of final diagnosis. When one patient has an organic lower urinary tract lesion concurrent with neurogenic dysuria is the most difficult diagnostic case. The diagnosis of such conditions necessitates the performance of ultrasound, neurophysiological, neuroimaging, and urodynamic studies. The neurogenic disorders are characterized by a concomitance of neurological and urologic symptoms that generally occur at the same time, by a change in urodynamic parameters, and by a positive effect of specific therapy encompassing anticholinergic, sympatholytic, and other neurotropic agents. Psychogenic dysurias are not attended by neurological deficit and the instrumentally signs of organic urinary tract lesion, but is always accompanied by the psychopathological symptoms of anxiety or depression. Moreover, there is a positive effect of psychotropic drugs (anxiolytics or antidepressants) and indifference to the use of neurourologic agents.

The review article presents data on the significance of activation of different components of the renin-angiotensin-aldosterone system (RAAS) in metabolic disorder progression and organ damage processes. Based on the analysis of the pharmacological properties of drugs and clinical evidence, the authors discuss the problems of the choice of RAAS blockers. The mechanisms of drug action on metabolic processes, atherogenesis, and vascular damage are discussed.

The paper provides a review of the literature on a relevant non-drug prevention problem, namely the negative effect of trans isomers of unsaturated fatty acids (trans-UFA) on the risk of circulatory system diseases (CSD) and other chronic noncommunicable diseases. It gives data on the specific features of the structure and ability of trans-UFA to elevate the plasma levels of atherogenic low-density lipoproteins and to lower those of non/antiatherogenic high-density lipoproteins. The natural sources of their moderate content in the animal fats from ruminants and those of their redundant content in the margarines manufactured by hydrogenation of liquid vegetable oils are described. A new technology for preparing soft margarines (spreads) is presented, which can produce fatty products that do not virtually contain trans-UFA. There is evidence that trans-UFA can considerably raise the risk of CSD and their acute complications. It is concluded that the manufacture of fatty products with low and even no trans-UFA levels should be expanded in Russia to improve its population's health.