A position agreement of the experts of Russian association of gerontologists and geriatricians, Gerontological society of Russian Academy of Sciences,  Russian medical society for arterial hypertension

Task Force Members: Tkacheva O. N. (Chairperson), Runikhina N. K., Kotovskaya Yu. V., Sharashkina N. V., Ostapenko V. S.

Expert Committee: Anisimov V. N., Arkhipov M. V., Baranova E. I., Boytsov S. A., Bolotnova T. V., Villevalde S. V., Galyavich A. S., Grinshtein Yu. I., Drapkina O. M., Duplyakov D. V., Zhernakova Yu. V., Zakharova N. O., Ilnitsky A. N., Karaeva E. V., Karpov Yu. A., Kisliak O. A., Kobalava Zh. D., Koziolova N. A., Konradi A. O., Martynov A. I., Medvedeva I. V., Moiseev V. S., Nedogoda S. V., Oganov R. G., Orlova Ya. A., Ostroumova O. D., Oschepkova E. V., Podzolkov V. I., Proschaev K. I., Skibitsky V. V., Fomin I. V., Frolova E. V., Khavinson V. Kh., Chazova I. E., Chesnikova A. I., Chukaeva I. I., Shabalin V. N.

Aim. To study the influence of age on the parameters of local vascular rigidity in healthy persons, and to assess correlations of carotid arteries rigidity in coronary heart disease (CHD) patients with arterial hypertension (AH)  of 1-2  grades   with assessment  of vasoprotective  effect  of a sartan — antagonist of angiotensin II receptors (AAR).

Material and methods. With an aim to study age and cardiovascular pathology  influence  on  the  parameters of local  rigidity, 44  healthy persons  included and 20 patients with AH of 1-2 grades  comorbid with proven  CHD. Local carotid  stiffness  was  assessed  by  ultrasound examination of carotid arteries, My Lab 90 device with the technology of radiofrequency analysis of vessel wall condition — echo tracking. Also, the influence was analyzed, of 24-week therapy by one of sartans  on structural and functional characteristics of carotid arteries.

Results. Comparison of the results of local stiffness in healthy group showed the local pulse wave velocity (PWV) in the range from 5,9±0,7 m/s  in those  30-39 year old to 6,6±1,1 m/s  in normotonics  >50 y.o., there  were  significant differences  in those  >50  y.o. comparing  with participants  <40 y.o. Analogical changes  were shown for the stiffness index β.  Together  with normalized  office blood  pressure (BP), AAR treatment  was  followed by a  decrease of local pressure in carotid arteries,  and decrease of carotid PWV from 9,9 (9,1; 11,5) m/s  to 8,3 (6,6; 8,6) m/s  with regression  by 17% (p<0,05).  Positive influence of AAR on structural and functional properties of carotid arteries confirms the significant growth of the coefficient by 3,3% (p<0,05), and decrease of stiffness  indexes  α &  β by 19,4% (р<0,05)  and  19,9% (p<0,01), respectively.

Conclusion. Parameters of local stiffness significantly correlated  with anthropometric parameters, duration of AH, systolic and diastolic BP in patients  with cardiovascular comorbidity. Therapy with sartan  followed by not only normalization of BP, but improved the parameters of local arterial rigidity.

Aim. To study prevalence of arterial hypertension (AH), mean values of  systolic  (SBP)  and  diastolic  (DBP) levels  of  blood  pressure, awareness of patients on this, antihypertension drugs (AD) intake and treatment  efficacy among inhabitants of Tyumen Region, age 25-64 year old.

Material and methods. A cohort of Tyumen Region inhabitants, 25-64 y.o.,  investigated  under  the  framework of multicenter  observational study ESSE-RF. Number of participants  — 1762, of those men 34,4% (n=607), women 65,6% (n=1155), mean age 48,9±11,4 y.o.

Results. In Tyumen Region the prevalence of AH was 48,9%, which is 4,9% higher than general  population in ESSE-RF (by 9 regions). The same  high pressure was  found  in general  population  of men  and women, however statistically significantly predominated  in men aged <55 y.o. The prevalence  of AH increased  with age  — from 17,1% in group  25-34  y.o. to 70,6%  in group  55-64  y.o.,  significantly more frequently registered  in rural inhabitants — 58,1% vs 46,8% (р<0,05) and those  with lower educational  level — 57,4% vs 47,9% (p<0,05). The specifics  of Tyumen Region was low level of awareness about having AH. In difference with the general ESSE-RF selection, with this value 73,1%, awareness on their AH in Tyumen Region was 57,6%. Naturally, this value was higher in women — 60,5% vs 50,6% (р=0,03), city inhabitants — 59,3% vs 51,7% (p<0,05) and persons  with middlelevel or higher education  — 58,4% vs 47,9% (p<0,05).  Not high was the portion of those regularly taking AD — 39,5%, of those effectively treated  39,1%.  Women with AH  significantly more  commonly  took AD — 43,9% vs 23,0%, and were doing this more effectively  — 43,2% vs 24,3% (р<0,01). Efficacy of AD was higher among those with higher education  — 44,7% vs 35,9% (р<0,01),  decreased with the age and did not relate  on the type of settlement.  Of the specifics  of Tyumen Region was not high portion of those with AH reached  target values of BP — 15,4% vs 22,7% in general population of ESSE-RF. This value did not have significant differences  depending  on the  age  and  type of settlement, but was significantly higher among women in the age group >35 y.o., citizens, as  rurals. Correlation of effective BP control with educational  level was found only in male population. Among hypertensive males with middle and higher education, BP control was significantly better comparing to AH patients with low educational level.

Conclusion. The results determined  the aims of prevention work with AH taking the specifics of this factor prevalence in Tyumen Region.

The issue of non-communcable diseases risk factors is one of the main in global targets of healthcare.  However the key point in this direction is still a  patient-clinician  communication  that  demands   high  level  of understanding and  empathy.  A  useful tool for clinical work might be person-centered interview.

Aim. To evaluate epistemological role of person-centered interview and to define its place in cardiological care for acute  myocardial infarction patients (MI).

Material and methods. The study is done in qualitative methodology: in-depth semistructured interview. Totally, 216 consequent MI patients screened. After inclusion  criteria  assessment  (economically  active males  with first MI, none  severe  comorbidities  and  no anamnesis  of coronary heart disease)  and study procedures, 14 interviews included into analysis  by phenomenological  descriptive  with the  elements  of interpretation, method.

Results. A range of non-expressed experiences  revealed of the living through of the disease state in this group of patients: serious life change, borderline of life “before” and “after”; anxiety and fear of sudden death and repeat  of the event; discourage  and confusion; puzzlement; disorientation in symptoms,  misunderstanding;  loss of perspective  for better  in life; stigmatization; self-image  changes; feelings of guilt and resentment;  somatic markers; specifics of social stress.

Conclusion.  Person-centered  interview as  a  method  of  dialogue, implemented  to  the  work of clinician, makes  it to  reveal  the  nonexpressed  but  very important  sides  of  the  disease   course.   In the experiencing of males with first MI, economically active, there is a range of issues  requiring specific  work. Addressing  to the  phenomenal  of patients  might be  a  higher  level position  in the  work with life style determined non-communicable diseases.

Aim. To study clinical results and safety of delayed vs urgent stenting with application of modern  antithrombotic drugs  in massive coronary thrombosis  in patients  with ST-elevation acute  myocardial infarction (STEMI).

Material and methods. Totally, 28 STEMI patients  included, age  52 (25-77) y.o., of those males 80% (n=23), who, during January 2014 to February 2016, in first 6-12 hours from the onset of the disease, received endovascular  treatment  with purpose  to recover adequate blood flow without urgent  stent  implanting into  infarct-related  artery.  Minimal invasive strategy with the aim to recover antegrade blood flow up to TIMI 2-3 was done for 14 (50%) patients. In all patients, after restoring of the antegrade flow, there was thrombus, visualized in artery lumen, with TIMI thrombus grade score (TTG) ≥3. Another criteria of efficacy was resolving of ST elevation by ≥50%. As antiplatelet support during the intervention all patients  received the combination of IIb/IIIa blockers  (eptifibatide) and 600 mg clopidogrel or 180 mg ticagrelor. Second coronary arteriography (CAG) was done in up to 5 days.

Results. By 4,0±1,0 day, blood flow TIMI 2-3 in infarction-related artery was secure in 100% patients; there was marked decrease of the grade of target   stenosis   in  infarction-related   artery   from  77,8±10,2%   to 50,5±19,5%;  decrease by its length from 21,5±8,5  to 15,5±5,5  mm; increase  of the reference  diameter  of artery from 3,1±0,8 to 3,5±0,75 mm, and thrombosis bride by TTG — from 3,9 to 0,9. By the data from CAG, stenting of the target segment  was done in 8 (29%) patients, and in 3 (10%) stenting done based on the data from intravascular ultrasound. In 17 (61%) patients the infarction-related stenosis was non-significant. In the group of delayed stenting there was no cases  of no/slow-reflow development. At hospital stage  of management, there were no cardiovascular events in the observation group.

Conclusion. In patients  with massive thrombosis  of infarction-related artery  (TTG ≥3) and  restored  antegrade coronary  flow TIMI  2-3,  the delayed stenting is a safe and effective strategy of treatment at hospital stage.

Aim. To address the complex approach  to observation and medication therapy  with assessment of efficacy and  safety  of monotherapy  by antiarrhythmic drugs (AAD): propafenon, sotalol, verapamil in comparison  with non-AAD controls,  for prevention of recurrent  atrial tachiarrhytmias  in early  and  later  post-operation  time  of  catheter isolation of pulmonary veins ostia.

Material and methods. Randomized by “envelope” method, and by the design of the study, 243 patinets included, 142 (58,44%) males and 101 (41,56%)  females,  age  25-79  y.o. (mean  — 56,09±10,14  y.o.) with anamnesis  of 4,48±2,6  years,  and selected  to 4 similar groups:  1 gr. (n=61) prescribed  AAD by Vaughan Williams class 4 — verapamil retard 240 mg/day, 2 gr. (n=62) — AAD class 1С — propafenon 450 mg/day, 3 group (n=60) — AAD class 3 — sotalol 160 mg/day, and 4 control group (n=60) — non-AAD. Follow-up lasted from 365 days (±10 days). Study methods:  patient  diary, ECG, Holter ECG, and  half of the  patients underwent implanting of subcutaneous monitor Reveal® (Medtronic).

Results. Total efficacy of ostium isolation after one procedure  was 66,6% (n=162, 95% confidence interval (CI) 61-72%), 67,2% (n=123, 95% CI 60-74%)  at the background  of antiarrhythmic therapy,  and 65% (n=39, 95% CI 52-76) non-AAD (р=0,75). In 81 (33,4%) patients AAD was non-effective, of whom 62 (25,5%) were operated  second time.  After two procedures, total  efficacy reached  88,5%  (n=215, 95% CI 84-92%), with AAD — 88,55% (n=183, 95% CI 83-92%) and non-AAD — 88,33% (n=53, 95% CI 78-94%)  (р=0,83).  There were differences   in  groups  during  early  post-operation  period  by  the number  of  medicational  and  electrical  cardioversions,  as  by  the number  of hospitalizations related  to arrhythmia. Mean number  of hospitalizations in 3 months was 0,654±0,74 cases. In group 1 it was 0,684±0,73  vs controls non-AAD — 0,894±0,88  (р=0,178), group 2 (propafenon)  — 0,447±0,57  vs controls  — 0,894±0,88  (р=0,0016) and  in group  3 (sotalol) — 0,592±0,67  vs controls  — 0,894±0,88, resp. (р=0,044).

Conclusion. AAD  in post-operation therapy  of catheter  isolation of pulmonary veins ostia  does  not  influence  the  outcomes  of invasive treatment   after  one  or  two operations,   however  influences  clinical course  of post-operation period, decreasing the number of medication and electrical cardioversions and significantly decreasing the number of hospitalizations related to cardiac arrhythmias.

Aim. To assess the  relation of age-depended changes  in heart  rate variability (HRV) with telomere  length.  With the  age,  even  with no cardiovascular  diseases (CVD), there  is a decline of HRV which is an indicator of vegetative system condition. The probable  mechanism  for age-related decrease  in HRV might be  cellular ageing.  One  of the markers of cellular ageing is telomere length regarded  as a marker of biological age.

Material and methods. Totally, 229 persons of age 23-91 y.o. included, with no clinical signs of cardiovascular diseases. All participants underwent the HRV analysis by the data of Holter ECG monitoring and of short ECG recordings supine and upright position by 5 minutes. Telomere length was assessed in leucocytes on genomic desoxyribonucleic acid (DNA) with plymeraze chain reaction  real time. The participants  were selected  to two groups: <60 y.o. and ≥60 y.o. Comparative analysis was done,  of the  parameters  studied,  in two age  groups,  correlational analysis  of telomere  length  with HRV, linear regression  analysis  and multiple regression.

Results. In the group of the older, telomere length was higher than in the  younger  — 9,90±0,47  units vs 9,65±0,43  units (p<0,001)  with close correlation of telomere length with the age (r=-0,32, p<0,05). By the data  of linear regression,  telomere  length is closely related with the mean value of standard deviations of all selected  RR intervals for every 5 minutes of 24-hour recording (SDANN), with the power of high-frequency spectrum  (HF), relation of lowerand high-frequency waves (L/H) (β=0,36,  p=0,006; β=0,39,  p=0,004; β=-0,32,  р=0,02, resp.). In older persons, in the group of shorter telomeres there were significantly lower values of mean standard  deviations for all selected R-R-intervals (SDNN) (111  (94;  126)  ms  vs 122  (112;  122)  ms), mean-square differences  between  the  duratons  of the  next  sinus intervals RR (RMSSD) R-R (RMSSD) — 16 (11; 22) ms vs 22 (17; 25) ms), power of the very low frequency spectrum  components  (VLF) — 1176 (718; 1453) ms2   vs 1476 (850; 1763) ms2)  by the  data  from Holter ECG, than in the group of longer telomeres (p<0,05). Differences by the shorter  recordings  supine  and  upright were not significant.

Conclusion. Telomere length is related to the age-relevant HRV changes. Telomere  length  might  be  an  early  predictor  of the  ageassociated weakening of autonomous  regulation of heart  functioning and reflect real biological age of vegetative nervous system irrelevant to other cardiovascular risk factors.

Aim. To assess the efficacy of physical cardiorehabilitation in patients with acute  coronary  syndrome  non-ST-elevation  (NSTEACS)  and percutaneous coronary intervention (PCI) on infarction-relevant artery.

Material  and  methods.  To  the  prospective   study,  35  patients included — mean  age  57,9±9,7  y.o.; 78% males,  22% females  after NSTEACS  with urgent  PCI on  symptom-dependent artery  and  noncomplicated  post-surgery period. Time of inclusion into the study was 2-8 weeks after ACS onset.  At 1 and 12 weeks of cardiorehabilitation programs there was functional (echocardiography, electrocardiography, exercise testing) and laboratory diagnostics  (lipids and chemistry). For 12  weeks  the  participants  visited 3  times  per  weeks  the  standard cardorehabilitation trainings.

Results. After the  cardiorehabilitation  course,  in patients  we found decreae of total  cholesterol  from 4,4±1,4  to  3,9±1,1  (р=0,02);  low density lipoproteides level from 2,6±1,1 to 2,1±0,7 (р=0,002); significant increase  of high density  lipoproteides  from 0,9±0,3  to  1,2±0,4  min (р<0,001)   and  left  ventricle  ejection  fraction  from  55±8,3%  to 60,6±8,2% (p<0,001). Significant decrease of the resting heartrate (HR) from 72,9±10,3  bpm to 67,9±6 bpm (р=0,04); mean  time of the HR recovery from 4,1±1,2 min to 3,8±1 min (р=0,03) and blood pressure from 4,2±1,1 min to 3,8±1 min (р=0,013) after exercise testing; significant increase   of exercise  tolerance  to  physical  exertion  from 4,0±1,5 МЕТ to 5,0±1,7 МЕТ (p<0,001) and time of test from 5,0±1,9 min to 6,7±2 min (p<0,001).

Concusion. 12-week program of cardiorehabilitation leads to significant normalization of carbohydrate  and lipid metabolisms, helps to increase exercise   tolerance   and  significantly recovers   the  hemodynamical parameters of circulation.

Aim.  To  study  some   aspects  of  antihypertension   therapy  (AHT) adherence in patients  with arterial hypertension  (AH) and  metabolic syndrome  (MS) by an  example  of fixed combination  of ramipril and amlodipine,  under  the  framework  of GRANAT-1  trial (Observational Program   for  Patients   with  Arterial  Hypertension   and   Metabolic Syndrome).

Material  and  methods. Totally,  101  patient  included,  having  had confirmed AH and MS. All participants completed the study. All patients consented to participate, had been recommended the combination drug AHT — fixed  combination of ramipril and amlodipine (Egipres) in various dosages selected  by clinician in routine assessment. Every patient was invited to clinic for 4 visits during 5 months with interval 1-2-2 months (visits 1-4).  For  assessment of  the  general  adherence  to  clinician recommendations (CR) during the first and final visits, all patients filled the Moriskos-Green test (MG) including 4 questions. In all visits, patients were assessed BP level, heart  rate,  and  during visits 2-4  there  was adverse events evaluation (AE). Also, the real adherence was evaluated by  the  intake  of Egipres,  and  activeness   of clinicians towards  the achievement of target BP levels in participants.

Results. The recommended AHT started taking 95 patients, by the end Egipres was being taken by 92 participants, 9 of them took other AHT. 90 patients achieved target BP (81 taking Egipres). Effect of the prescribed at visit 1 AHT in most patients appeared by 1 month (visit 2): in every third patient the target BP was reached,  and mean systolic BP decreased by 17,2 mmHg and diastolic BP by 7,7 mmHg (visit 2), and 31,0 mmHg and 16,1  mmHg,  resp.  — by visit 4.  Totally, 3  AE  registered,   probably amlodipine-related.  A significant improvement of total adherence was found: if at the beginning of study, by MG test only 22 (21,8%) adhered, by the end — 70 (69%) of patients.  In three  cases  there  was lack of clinician activity to help achieve target BP.

Conclusion. Single-time usage  of the fixed combination of amlodipine and ramipril, its high efficacy and safety with regular visiting of physician help to increase general adherence of patients to treatment.

Comorbidity of diabetes  mellitus (DM) with arterial hypertension  (AH) leads to four-time increase of cardiovascular risk (CVR). Achievement of target blood pressure (BP) is one of the main strategies of cardiovascular complications  prevention in DM patients.  Efficacy of azilsartan medoxomil is higher than of other drugs from the group.

Aim. To study changes  in peripheral and central BP daily profile andparameters of arterial stiffness in replacement of RAAS blocker as a partof two component  antihypertension  therapy (AHT) by 40 mg azilsartan medoxomil for patients with AH and type 2 DM, with dose titration to 80 mg if target BP not reached.

Material and  methods. Thirty AH+DM2  patients  not  having targetBP<140/85  mmHg on two component  AHT (53% females,  mean age60,4±7,6  y.o.,  40%  smokers).   Replacement   of  RAAS blocker  by azilsartan medoxomil 40 mg with dose increase to 80 mg in 6 weeks if BP  <140/85  mmHg not achieved. Folow-up lasted for 12 weeks. 24-hour profile of peripheral and central BP and parameters of arterial stiffness were assessed with BPLab Vasotens (JSC “Piotr Telegin”). The results were statistically significant in p<0,05.

Results. In 12  weeks  of therapy,  25  patients  (83%) reached   the target peripheral BP<140/85 mmHg. The increase  of azilsartan medoxomil at week 6 was needed  in 11 (37%) patients.  In 12 weeks there  was significant decrease in clinical peripheral  and central  BP (from   160±16/89±9    mmHg   to   125±7/73±6   mmHg  and   from 144±11/84±4  mmHg to 115±9/67±5  mmHg, respectively), decrease of the  mean  daily peripheral  BP by 22/9  mmHg, central  by 18/13 mmHg, mean nocturnal BP by 24/9 mmHg and 19/10 mmHg, respectively.  There  was  significant  decrease  of  daily and  night variability of SBP (from 15±4 to 10±3 mmHg and from 11±3 to 8±2 mmHg, resp.),  decrease of PWV (from 10,2±2,3 to 9,5±2,2 m/s) and augmentation   index  (from  24,6±8,6  to  13±7,0%),  р<0,05  for  all differences.  There were no significant changes  in PP amplification. Improvement of 24-hour  BP (ABPM) led to increase  of the dippers portion: improvement of SI SBP at azilsartan medoxomil was found in 53% cases. There was decrease of the level of morning SBP raise: from 34±13 mmHg to 25±10 mmHg (р<0,05). The drug demonstrated metabolic neutrality and good tolerability.

Conclusion. Replacement  of RAAS by azilsartan medoxomil in AH and DM2 patients  taking bicomponent  AHT leads to achievement  of target clinical BP in 83%  of patients,  normalization of 24-hour  profiles of peripheral  and central  BP and improvement of parameters of arterial stiffness in most patients. Azilsartan medoxomil therapy tolerated good and is metabolically neutral.

Aim. To assess the efficacy of regional system of multidisciplinary care in pulmonary hypertension (PH).

Material and  methods. In a  single-center, pro and  retrospective cohort  study,  2001-2015,   the  epidemiological  characteristics  and yearly mortality from PH were assessed in the created  in late 1990s multiple system of PH management in the Udmurt Republic. According to the specific drug therapy tactics, there were three periods of observation: in 2001-2005 PH patients received, by indication calcium channel blockers and supportive therapy; in 2006-2010  sildenafil was added; from 2011 pulmonary arterial hypertension (PAH) patients also received bosentan, ambrisentan, and in chronic thromboembolic PH —inhaled iloprost.

Rеsults. In the  cardiology  and  rheumatology  clinic of the  Udmurt Republic, a multidisciplinary system of PH management was shaped, with three-stage  individualized care   of  patients,   beginning  from newborn  period  (1st    stage   — pre-hospital,   2nd    — hospital,  3rd    — rehabilitation). Within  the  first 5 years  of follow-up, mortality of PH patients was 15-12% per year, from 2006 to 2010 — 10-7,5% per year, in 2011-2015 — 5,6–3,8% (р2015-2001=0,008).

Conclusion. Interprofessional  approach   to  PH patients  care  in thecircumstances of regional center  and  therapy  by PAH-specific drugs significantly increased  survival rate of patients.

The treatment  adherence problem  is one  of the  most  significant for medicine and society. The article focuses  on the main aspects of the adherence problem: modern view on terminology of this issue, various factors classification influencing adherence, diagnostics  of adherence. A  review is presented of the  ways to  improve adherence, that  are provided by modern science to apply into clinical practice. The necessity confirmed, to consider the issues related to adherence, with obligatory taking the quality of such therapy, as only high quality treatment can be, being adhered, successful in the main goals: improvement of prognosis of the diseae and life, improvement of patients life quality.

The article focuses  on the  contemporary  view on the  relation of air pollution by particulate matter (PM) with morbidity and mortality from the brain stroke. The results of studies are reviewed, on the longand shortterm influence of PM pollution on cardiovascular system depending  on their size, origin, chemistry,  concentration  in the air, as  the ways for stroke prevention.

Main clinical specifics  of  the  non-compaction   myocardium  of  left ventricle (NCM) are heart  failure, arrhythmias and thromboembolism. Severe trabecularity and deep intertrabecular spaces might be the origin of blood congestion and formation of clots inside the left ventricle (LV). The article focuses on the recent aspects of anticoagulation in NCM, and presents clinical case of man 54 year old with NCM diagnosis, admitted with symptoms of severe heart failure and multiple clots in LV, complicated with repeat systemic embolism. Later, after patient’s voluntarily decrease of treatment,  repeat  thrombosis of the LV developed,  with embolism in the left brachial and in popliteal arteries.  All patients  with NCM, as asecondary prevention of thromboembolism, a permanent anticoagulation is indicated. Also, as a primary prevention, anticoagulation is needed for NCM patients  who need  thromboembolism risk factors,  such as atrial fibrillation and systolic dysfunction of the LV.