In 2018, at the annual congresses of the European Society of Hypertension and European Society of Cardiology, the updated guidelines on the diagnostics, management and prevention of arterial hypertension were announced, followed by their publication in the European Heart Journal. The guidelines present a comprehensive overview on the definition and classification of arterial hypertension, approaches to the blood pressure measurement, assessment of the target organ damage, special patient subgroups and other issues. Despite a detailed analysis of various issues of the diagnostics and treatment of hypertension, some of the statements appear to be disputable and raise discussion among specialists in hypertension field. The diagnostic criteria, threshold and target blood pressure levels are the most debatable issues involving comparisons with the guidelines of the American Heart Association (2017). This paper gathers a number of comments on the less discussed questions of the diagnostics, treatment and prevention of hypertension. This collection of letters of the specialists, members of the Russian Society of Cardiology includes both personal expert opinions and well-known facts, reflects the controversy of the available evidence and indicates the blanks and gaps in hypertensiology giving perspective for potential future studies.

Arterial hypertension (HTN) needs new treatment methods, including invasive ones, because HTN has severe consequences and involves all regulating systems (neuro-cardio-renal/cerebral continuum). It is often associated with comorbid pathology (obesity, atherosclerosis, sleep disorder, diabetes mellitus, etc.). The paper presents a summary of the position of the European experts on some invasive methods of HTN treatment — “DEVICE-BASED TREATMENT” (DBT) in the section of new recommendations of the European Societies of Cardiology/Hypertension (2018 ESC/ESH Guidelines for the management of arterial hypertension), including carotid baroreceptor stimulation, renal denervation, arteriovenous fistula formation and other. The experts do not recommend to use DBT in routine practice, confirm high requirement and demand of clinical and basic investigations to prove their safety and efficiency.

The 2018 ESC/ESH European guidelines for the management of arterial hypertension (HTN) include new statements concerning the role of psychosocial factors in the course and the control of HTN. The importance of adherence to treatment is emphasized and efficient interventions that may improve drug adherence in HTN are presented. However, the Guidelines do not reflect the contemporary knowledge on psychosocial aspects of HTN and their meaning is not presented. It is necessary to integrate psychological concepts into the clinical guidelines, and clinical psychologists should take part in the development of such important documents.

The 2018 Joint Guidelines of the European Society of Cardiology and the European Society of Hypertension Specialists present a successful attempt to revise the approach to one of the most prevalent health problems worldwide. For more than two years, a Task Force of experts from the two Societies have assessed and have investigated the most recent scientific advances in the field of hypertension (HTN) in order to provide doctors with the adequate diagnostic tools, evaluation of cardiovascular risk and the optimal drug treatment. Undoubtedly, among a number of crucial changes of target blood pressure (BP) range along with the new sections dedicated to HTN in different circumstances, one can notice equally valuable, albeit subtle remarks about out-of-office BP and closely related telehealth. Extensive use of ambulatory and self-BP monitoring forced to match it to office BP. Booming information and communication technologies applied successfully in various therapeutic areas and have taken place in the Guidelines. From now digital health becomes a piece of the follow-up and adherence control. This brief report highlights the current position of European experts on telemedicine and outpatient methods of monitoring blood pressure.

The article discusses four statements of the position agreement of the Russian experts on the treatment of arterial hypertension in patients over 80 years old, as well as in patients with senile asthenia. These statements consider recommendations on the threshold and target blood pressure levels, on the initial antihypertensive therapy (monotherapy or combination therapy), the initial doses of the drugs (low or high) in patients over 80 years old with or without senile asthenia. The authors believe that these statements require some correction as they do not fully correspond to the results of the HYVET trial. The level of evidence and recommendation class stated in the position agreement are disputable and give rise to doubt. The authors compare the position agreement by the Russian experts and European guidelines 2013 and present the evidence of the large randomized clinical trials and meta-analyses.

The majority of patients with stable arterial hypertension require combination therapy which is supported by the clinical evidence. The established target levels of blood pressure below 130/80 mmHg are challenging and demand multiple drug combinations in a single patient. Therefore, the use of dual and triple combination therapy is getting wider, and rational triple fixed combinations are highly relevant. The updated guidelines on the diagnostics, management and treatment of arterial hypertension of the European Society of Hypertension and the European Society of Cardiology confirm and recommend early and wider use of the fixed-dose drug combinations. The paper reviews the main practical issues of the use of combination therapy, including key questions of the change from free dose to fixed dose combinations and their rational choice.

The paper summarizes the main methods of automatic non-invasive assessment of the blood pressure (BP) dynamics. The advantages and disadvantages of BP measurement according to Korotkoff sounds and the oscillations in the brachial cuff are discussed. Currently, BP is measured during deflation of the cuff, while the pressure in the cuff should be inflated (by about 20–30 mm Hg) above the systolic BP. The BP level before measurement can be unknown, thereby increases the possibility of raising the pressure in the cuff above the optimum. In connection with this, recently, methods for determining BP during inflation of the cuff have been proposed. The BP value, determined both by Korotkov’s tone and by oscillometry during inflation, differs from that during the deflation of the cuff. The difference varies with age and BP and in a number of cases is clinically significant. The causes and consequences of such differences are discussed. In intensive care units and in operating rooms, continuous BP measurement is necessary. In comparison with the discrete measurement of BP, it allows to detect timely hypotension, to evaluate its duration, which improves the management of the patients. The invasive method of BP detection has known limitations and complications which stimulated the development of devices for non-invasive BP control. Despite the comparisons of the accuracy of such measurement methods, this issue continues to be debated. Thus, the methods of non-invasive control of BP level, discussed in this review, reflect both their advantages and limitations, which dictates the need for further research in this field.

Retinal vein occlusion (RVO) is an acute vascular retinal disorder, which is associated with local or general endothelial dysfunction. Up to 25 % of RVO cases occur in young and middle-aged patients. The article reviews possible causes of RVO in young and middle-aged subjects. The authors pay attention to independent risk factors for RVO including arterial hypertension, dyslipidemia, diabetes mellitus and acquired and hereditary thrombophilia. Considering a multifactorial origin of RVO, the authors emphasize the need for a multidisciplinary approach in the management of patients with RVO.

Polycystic ovary syndrome (PCOS) is a common endocrine disease in women of reproductive age.
In addition to hyperandrogenism, impaired ovulation and fertility, PCOS is associated with an increased detection of cardiovascular risk factors such as obesity, insulin resistance, impaired glucose tolerance, type 2 diabetes mellitus, arterial hypertension, and obstructive sleep apnea. The initial stages of the atherosclerotic process are also well documented in women with PCOS. However, data from prospective studies on the end points of cardiovascular morbidity and mortality are scarce and controversial. Perhaps this is due to the fact that PCOS is a heterogeneous group of endocrine, metabolic and reproductive disorders, and different authors consider various combinations of these disorders as the syndrome. Different phenotypes of PCOS may be associated with different cardiovascular risk. Women with a “complete” phenotype (a combination of all three PCOS diagnostic criteria) and with the predominant hyperandrogenism have higher risk. According to a number of studies, obesity affects more than half of women with PCOS and contributes the most to the increased risk of type 2 diabetes mellitus. Despite the weakness of the evidence regarding the association of PCOS with cardiovascular morbidity and mortality, most international organizations recommend active screening for cardiovascular risk factors in women with PCOS.

Background. Vagus nerve stimulation has been proposed for the treatment of a number of diseases. The positive effects of vagus nerve stimulation on ischemic and reperfusion myocardial injury has been tested in experimental models. However, the escape effect of vagus activation on heart rate and the methodology to overcome this effect have not been reported properly.

Objective. The purpose of the study is to evaluate parameters of prolonged stimulation that decrease heart rate and allow overcoming the escape effect of vagus nerve activation.

Design and methods. We used Wistar rats (n = 9). Cervical section was performed under general anesthesia. Left vagus nerve isolated from adjacent tissue was contacted with custom stimulation electrodes and a custom pulse generator. Blood pressure was measured in the right common carotid artery. Limb electrocardiogram was continuously recorded. First, stimulation parameters repeatedly evoking vagal reaction (decrease in heart rate) without nerve damage were evaluated. Second, parameters of intermittent stimulation that allowed repeat and consistent heart rate decrease were assessed.

Results. During experiments, in 5 animals the following parameters leading to sustained 30 ± 20 % heart rate reduction were found: rectangular pulse, 30 Hz, 0,5 ms, 1–2 V (0,6– 0,8 mA). Stimulation with 50 Hz frequency led to nerve damage in 1 case. Stimulation with 20 Hz frequency led to heart rate over-suppression of heart rate and blood pressure. Intermittent nerve stimulation was tested in 4 animals and led to repeated heart rate decrease by 38 ± 15 %. The parameters which helped to avoid escape effect on heart rate change were the following: the length of stimulation episode of 45 s and interruption of stimulation for 15 s.

Conclusion. Intermittent electrical stimulation evokes vagal reactions on heart rate and allows overcoming the escape effect of vagal activation. 

Background. Previous studies implicated cardiotonic steroids, including Na/K-ATPase inhibitor marinobufagenin (MBG), in the pathogenesis of preeclampsia (PE). Recently, we demonstrated that MBG induces fibrosis in cardiovascular tissues via mechanism involving inhibition of Fli1, a nuclear transcription factor and a negative regulator of collagen-1 synthesis.

Objective. We hypothesized that in human and rat PE, elevated MBG level is associated with development of fibrosis of umbilical arteries and rat thoracic aortae.

Design and methods. Twelve patients with PE (mean blood pressure (BP) 118 ± 4 mmHg; mean age 28 ± 2 years; mean gestation age 36 ± 1 weeks) and 12 gestational age-matched normal pregnant subjects (mean BP 92 ± 2 mmHg; mean age 26 ± 1 years; mean gestation age 37 ± 1 weeks) were enrolled in the clinical study. We tested 16 pregnant Sprague-Dawley rats. Hypertension was provoked in 8 rats by 1,8 % Na supplementation.

Results. PE in humans and rats was associated with the higher plasma MBG level and was associated with five-fold decrease in Fli-1 level and four-fold increase in collagen-1 level in the PE umbilical arteries vs. those from the normal subjects (p < 0,01). Isolated rings of umbilical arteries from the subjects with PE exhibited impaired response to the relaxant effect of sodium nitroprusside vs. control vessels (EC50 = 141 nmol/L vs. EC50 = 0,9 nmol/L; p < 0,001). Similar results were obtained for thoracic aorta of rats with experimental PE.

Conclusions. These results demonstrate that elevated MBG level is implicated in the development of fibrosis umbilical arteries in PE. 

Objective. To assess the impact of the achieved blood pressure level on the structure and function of kidneys, carotid arteries and depression level in hypertensive post-stroke survivors.

Design and methods. Carotid arteries and kidneys were assessed by ultrasound study. All parameters including depression level (Hamilton scale) were evaluated depending on the achieved systolic blood pressure level (SBP) in 88 hypertensive patients in acute post-stroke period and at follow-up (8–12 months after stroke). Multiple regression analysis was applied to assess the associations between the factors.

Results. Office SBP directly correlates with the creatinine level (r = 0,5; р = 0,01). Moderate direct correlation was found between mean office SBP at the follow-up visit and intima-media thickness (IMT) (r = 0,47; р = 0,004), resistance index of the right common carotid artery (CCA) (r = 0,47; р = 0,006), resistance index of the left CCA (r = 0,5; р = 0,002), and resistance index of the left internal carotid artery (ICA) (r = 0,4; р = 0,02). Regression analysis demonstrated that mean office SBP has an impact on the following parameters: plasma creatinine level (β = 0,43; р = 0,04) and CCA IMT (β = 0,36; р = 0,03). The depression decreased in subjects with SBP 125–134 mmHg.

Conclusion. SBP stabilization at the level 125–134 mmHg leads to the decrease in the resistance index of the carotid arteries, improves renal function and reduces depression level in post-stroke survivors.

Background. One of the key problems of keeping records in medical information systems is the correctness of the data entry. Even the simplest decision support systems (DSS) can be highly useful regarding the reduction in the number of errors in entering data and recommendations.

The purpose of this study was to assess the effectiveness of the implementation of the simplest DSS, designed to minimize the number of input errors of the patient’s key characteristics and to implement a basic control for the recommendation section.

Design and methods. DSS was developed as a data analysis system of a medical information system that can perform functions directly integrating into a working medical information system. The study involved 7 cardiologists of the counseling and diagnostic center of the Almazov National Medical Research Centre (St Petersburg, Russia), who tested the established DSS for 10 weeks as part of their daily work on counseling patients with arterial hypertension. Altogether 1280 records were analyzed in the main group and 1060 in the control group. 

Results.In the group with notifications enabled, the total number of errors in the same section comprised 49,1 %, while 84,7 % of them were recorded during the first week of using the system, and by the time of the visit only 8,7 % of the errors were registered. In the control group, the total number of errors was 63,7 %, while 42,2 % remained uncorrected. In the recommendation section, the number of errors was almost identical in both groups, 24 % in the group that worked in the “fixation” mode, and 25,5 % in the group with error notifications enabled. At the same time, in the latter one, at the end of the visit, 7 % errors remained uncorrected. In a detailed analysis of the data in the “physical examination” section, the largest number of missing data related to the anthropometric indicators, especially the waist circumference. When assessing the quality of input data, we found that the group with enabled notifications showed a progressive decrease in the number of errors and unfilled fields in the “physical examination” section.

Conclusion. The use of the simplest DSS in the outpatient admission of patients with arterial hypertension can significantly improve the quality of the input of structured data necessary for patient risk stratification. It also contributes to the patient’s safety in terms of the correctness of the medical prescriptions.

Objective. To investigate the effect of necroptosis inhibition on the morphofunctional state of the myocardium and the expression of microRNA 223 after heterotopic allogeneic heart transplantation in rat.

Design and methods. Twenty Wistar rats were examined in the study. Animals were divided into the following groups: 1) control (n = 7), 2) dimethyl sulfoxide (DMSO) (n = 6), 3) necrostatin-1s (n = 7). Necrostatin-1s was used as an inhibitor of necroptosis, which was administered intraperitoneally in DMSO solution 1 hour before the start of the experiment at a dose of 1,65 mg/kg. HTK solution cooled to 4 °C was used as a preservation solution. Two hours after heart arrest, the heart was heterotopically transplanted in the abdominal cavity of recipient rat using the scheme “aorta-aorta, pulmonary trunc-posterior vena cava”. Three hours later, intracardiac hemodynamics was assessed by recording the pressure in the left ventricle, heart rate and coronary flow rate in Langendorff-perfused heart. The expression level of microRNA 223–5p and –3p in left ventricular myocardium was assessed using real-time polymerase chain reaction. The plasma levels of troponin I were assessed by enzyme immunoassay. Myocardial infarct size was measured planimetrically at the end of the experiment by staining myocardium with triphenyltetrazolium chloride.

Results. Inhibition of necroptosis significantly improved the morphofunctional state of the myocardium, which manifested in a decrease of myocardial infarct size in the necrostatin-1s group compared with the control group and DMSO group. Thus, in the necrostatin-1s group, myocardial infarct size was 25 ± 8,7 %, which was smaller than in the control and DMSO groups (56 ± 9,5 and 57 ± 8,7 %, respectively; p < 0,05). Also in the necrostatin-1s group, lower diastolic intraventricular pressure was recorded, as well as higher values of pulse intraventricular pressure and coronary flow rate than in control group and DMSO group (p < 0,05). Left ventricular myocardium in the necrostatin-1s group demonstrated higher expression of the antinecroptotic miRNA 223–5p and –3p as compared with the control and DMSO groups, as well as lower plasma levels of troponin I (p < 0,05).

Conclusions. Pharmacological inhibition of necroptosis in heterotopically transplanted donor heart is accompanied by marked cardioprotective effects and increases the expression of antinecroptotic microRNA 223–5p and –3p.