[HYPERTENSIVE CRISIS: MODERN VIEW OF THE PROBLEM AND OPTIMIZATION OF DIAGNOSTIC AND THERAPEUTIC MODALITIES].

The data collected by Burdenko Military Hospital indicate that in the 1980s hypertensive crisis (HC) occurred in roughly 30% of the patients with AH. This value fell down to 16% by 2012, with a rise in the number of uncomplicated crises from 46 to 62%. Analysis of the causes behind these changes showed that half of the patients simply experienced an elevated arterial pressure with minimal clinical symptoms. The decrease in the number of complicated cases from 54 to 39% is doubtful bearing in mind that ICD-10 gives the status of nosological entities to complications of hypertensive crisis (stroke, myocardial infarction, etc.) but not to the HC syndrome proper requiring urgent hospitalization; due to this hypertensive crisis itself tends to be disregarded and not included in statistics. HC with acute clinically significant lesions of target organs requires intensive care or resuscitation using infusion of vasodilators and loop diuretics to stabilize arterial pressure. In case of uncomplicted HC and aggravation of hypertensive disease, the medications of choice are oral short-acting ACE inhibitors and imidazoline receptor agonists.

[Emergency state of health by arterial hypertension].

Emergency state of health by arterial hypertension. According to the Burdenko Main Military clinical hospital at the present time the frequency of crisis hypertensive heart disease is 16% from the total number of all patients with this nosology. Rapid relief of hypertensive crisis should be provided for patients' status assessment from the position of development of fatal complications. Herewith the main task when treating hypertensive crisis is not normotension, but reduction of blood pressure to safe level, taking into account potential risk of hypotonia and hypoperfusion in case of too aggressive hypotensive therapy. The main factor of hypertensive crisis development is the absence of compliance. The authors gave recommendations on treatment of complicated and non-complicated forms of hypertensive crisis, and provided indications for hospitalization.

[Refractory hypertension: diagnosis and treatment optimization].

Resistant hypertension occurs in up to 15% of patients with arterial hypertension in Russia. Medical treatment of resistant hypertension must include minimum 3 medications with maximum or maximum tolerated doses besides one of the medications must be diuretic. According to department of arterial hypertension of the Burdenko Main Military Clinical Hospital to achieve the target levels of arterial blood pressure it was necessary to prescribe 4-5 components antihypertension therapy in patients. Authors suggested an algorithm of diagnosis and treatment of patients with resistant hypertension with the help of surgical method. This method is based on decreasing of sympathic nervous system activity by selective break of neuronal connections with the help of interventional intravascular radio-wave ablation. Endovascular renal sympathetic denervation allows to effectively control arterial blood pressure, to optimize antihypertensive therapy, but this method does not cure from arterial hypertension.

[Applying of assessment scales for patients with severe community-acquired pneumonia in young patients].

One of the most important issues in the management of patients with community-acquired pneumonia is the correct initial assessment of the severity of the patient's condition. In the context of outbreaks of pneumonia among soldiers performing military service, this position is crucial. Up to date specialized scales were developed and used in clinical practice allowing assessing a risk on the basis of an adverse outcome, objectifying the decision on the choice of the place of treatment of a patient with community-acquired pneumonia. Various prognostic scales have their advantages and several disadvantages; in particular the possibility of their use to date has not been studied in the management of patients with pneumonia of organized groups. This publication is a brief description and analysis of the possibilities of applying the most well known scales in young people.

[The first experience with the use of catheter denervation of renal arteries in patients with refractory hypertension].

The prevalence of refractory arterial hypertension in Russia is estimated at 15%. We report the first experience with surgical treatment of this pathology. The method is based on the reduction of activity of the sympathetic nervous system by selective breaking of connections between of neurons with the help of interventional intravascular radiowave ablation. Renal endovascular sympathetic denervation allows to more effectively control AP and optimize antihypertensive therapy but does not ensure recovery from AH.

[Diagnostics and treatment of patients with sarcoidosis in multidisciplinary military hospital].

The authors analyzed the methods of diagnostics, clinical peculiarities of sarcoidosis in different groups of patients, treated in multidisciplinary military hospital. The authors also analyzed the possibility of estimation of optimum diagnostic and medical tactics on the basis of prospective observation after patients with morphologically confirmed sarcoidosis, treated in pulmonary department of the Main Military Clinical Hospital n. a. N.N. Burdenko.

[Hypertensive crisis: problems of diagnostics and paradigm of the treatment].

Analysis of causes of increase of the uncomplicated hypertensive crisis (HC) from 46 to 61% indicates that in the half of cases the cause was only high ABP with minimal clinical symptomatology. To refer all cases of the catadrome of hypertensive disease to hypertensive crisis is inappropriately. It is recommended to use with such concepts as "complicated" and "uncomplicated" HC also term "catadrome of hypertensive disease (instability of ABP)". It allows to except the hyperdiagnosis of HC and to optimize indication for hospital admission. There are recommendations for medical actions in case of complicated and uncomplicated HC and catadrome of hypertensive disease.

[Hypertensive disease: diagnostics and differential methods of antihypertensive therapy].

Diagnostics of hypertensive disease is performed according two-stage scheme recommended by Society of cardiology of Russian Federation (2010) and adapted by us for examination in Central Military Clinical Hospital n. a. N.N. Burdenko. First stage, as possible, should be carried out in out-patient departments, second stage, as it necessary, in specialized medical treatment facilities. Indications for admission of patient with hypertensive disease are abstrusity of diagnosis and necessity of carrying out of special, often invasive study, for updating of information about the form of arterial hypertension, difficulties in adjustment of antihypertensive therapy. Major criterion for adjustment of antihypertensive therapy is degree of cardiovascular risk. In the beginning of treatment monotherapy is preferable for patients with low and average risk of progression of cardiovascular disease, use of combination of two or three medications in small doses is reasonable for patients with high and very high risk of complications. Three medications were prescribed for 21% of patients, four or five for 14% of patients.

[Resistant hypercholesteremia in clinical practice: new insight into the causes and methods of treatment].

Coronary heart disease and other diseases caused by atherosclerosis, take first place among the causes of adult mortality. Leading role in the development of atherosclerosis belongs to violations of cholesterol metabolism. Reducing mortality from ischemic heart disease primarily associated with adequate correction of the lipid metabolism. The research of the possible causes and correction of resistant hypercholesterolemia is done. Determined that some patients with resistant to statins hypercholesteremia and normal or elevated levels of hormones T3 and T4 in the blood have isolated symptoms of hypothyroidism, which may be a manifestation of reducing tissue sensitivity to thyroid hormones. Adding to the statins levothyroxine in daily doses of 25-50 mkg have additional cholesterol reducing action, allowing to achieve target levels of lipoprotein in blood in patients. The use of levothyroxine in low doses in combination with statins is highly effective and economically justified.

[Clinical and morphological characteristics and factors of prognosis of pulmonary thromboembolism].

Analysis of 146,521 autopsy protocols in Moscow in 2001-2005 showed that the incidence pulmonary thromboembolism (PTE) as a direct cause of death was 3.8-7%. PTE was not diagnosed during life in 20-28% of the patients who had died at hospitals and in 68-72% of those who had died at home. PTE was 2-3 times more common in females than in males, the age of the deceased patients was old and senile. The sources of PTE were thrombi of the leg deep veins (93.2%), small pelvic veins (3.4%), and right heart chambers (1.1%). Thrombophilic states were one of the main causes of the poor course and outcome of PTE. Based on the studies performed, an algorithm was developed for the diagnosis and treatment, which was successfully used at the N.N. Burdenko Main Military Clinical Hospital. The introduction of the results could reduce the incidence venous thrombosis from 39% to 17%, that of cava-filter thromboses from 24% to 3.7%, and recurrent TELA from 15% to 5.6%.

[The clinical picture and outcomes of myocardial infarction which developed in a multifield hospital].

The aim of the investigation was to study most frequent clinical variants of myocardial infarction (MI) onset at a multifield hospital, as well as some features of its course and outcomes in patients undergoing treatment at different departments. The study found that the onset of intrahospital MI was often atypical, and that atypical onset was most frequent in cases of myocardial necrosis in patients undergoing treatment in surgical and therapeutic departments. The clinical picture, ECG data, and outcomes were analyzed in patients with MI whose onset took place at different hospital departments. The study revealed that the course of atypical variants of intrahospital MI, especially in surgical and therapeutic noncardiological patients, was more severe than in patients of cardiological departments.

[Arterial hypertension: the modern therapeutic strategy].

Arterial hypertension (AH) is a serious social and medical problem of our time. The review presents approaches to antihypertensive therapy taking into account the degree of cardiovascular complication risk; the main principles of pharmaceutical correction of AH are formulated.

[The cell immunity parameters in patients with acute coronary syndrome].

The subjects of the study were 75 patients with instable angina (IA) and 16 patients with chronic coronary heart disease (CHD) following transcutaneous transluminal balloon angioplasty (TTBA). Their examination included the evaluation of the changes of some cell immunity parameters, such as the levels of interleukins IL-1, IL-6, and IL-10, tumor necrosis factor alpha (TNFalpha), and serum neopterin (NEOP), the measurement of C-reactive protein level, the detection of certain viral agents in blood (herpes simplex virus (HSV), cytomegalovirus, Chlamydia pneuoniae) using polymerase chain reaction (PCR), The study revealed such signs of cell immunity disbalance as the pronounced activation of pro-inflammatory factors (IL-6, TNFalpha, and serum NEOP). Along with no changes of the activity of anti-inflammatory factors (IL-10), the research revealed the similar direction of immune shifts in IA patients and CHD patients who had no clinical signs of exacerbation and had undergone TTBA. Most patients displayed signs of persistent viral infection, which was HSV in the majority of cases.

[The main reasons for late diagnosis and errors in the early period of treatment of intrahospital myocardial infarction in a general hospital].

The purpose of the study was to investigate the reasons for late diagnosis and late transfer of hospitalized patients with myocardial infarction (MI) to a specialized cardiological department. The study shows that the main reasons are an atypical clinical picture of MI and a low "infarct alert" of doctors of different specialties. The authors analyzed the fullness of urgent medical aid and the beginning of treatment in cases of intrahospital MI in patients being treated in different hospital departments. The analysis revealed the main objective and subjective factors that cause a low frequency of administration of thrombolytics, anticoagulants, and disaggregants.

[The effects of mexicor on thrombocyte aggregation, blood viscosity, hemodynamics, and the clinical course of coronary artery disease].

The authors analyze their experience in the application of mexicor, a Russian cytoprotector, in 50patients with chronic coronary artery disease (CAD) and 51 patients with acute coronary syndrome. In additional to cytoprotective action, the use of mexidor in complex therapy of CAD lowers the functional activity of thrombocytes, eliminates high blood viscosity syndrome, and lowers low density lipoprotein cholesterol level. These favorable changes in hemorheological parameters improves myocardial perfusion, lowers the strength and frequency of coronary pain attacks, retards postinfarction left ventricular remodeling, and increases the quality of life of patients with various CAD forms.

[Early postoperative complications and prevention of them in ischemic heart disease patients after direct myocardial revascularization]. / Oslozhneniia rannego posleoperatsionnogo perioda i ikh profilaktika u bol'nykh ishemicheskoi bolezn'iu serdtsa posle priamoi revaskuliarizatsii miokdarda.

AIM: To specify risk factors affecting development and frequency of complications early after the bypass operation in direct myocardial revascularization. MATERIAL AND METHODS: 455 patients with ischemic heart disease (IHD) of whom 392 (86.2%) had stable angina pectoris class III-IV, 25 (5.5%) had unstable angina pectoris (UAP) and 38 (8.5%) had survived myocardial infarction (MI) underwent autovenous coronary artery bypass operation. IHD combined with arterial hypertension in 103 (22.6%), diabetes mellitus type II in 67 (14.7%), cardiac failure (CF) stage IIa in 97 (21.3%) patients. The ejection fraction (EF) was 37.8 +/- 3.3% in 113 (24.8) patients, in the others it was 46.7 +/- 2.7%. RESULTS: Early postoperative complications arose more frequently in patients with UAP, MI, CF and low EF. Postoperative acute cardiovascular failure was registered in 132 (29.5%) patients, arrhythmia--in 60 (13.4%), perioperative MI--in 13 (2.9%) patients. CONCLUSION: The most significant risk factors of postoperative complications in the above patients are the following: UAP, MI, CF, low EF. These risk factors should be allowed for in preparation of patients for coronary bypass surgery.