О. Denesyuk 

National Pirogov Memorial Medical University, Vinnytsya

Introduction. The study of the dependence of the degree of vascular remodeling, endothelial dysfunction on the height of blood pressure (BP) in the case of hypertension (AH), coronary heart disease (CHD) is an urgent problem in cardiology.

The endothelium is an organ of 1.5-1.8 kg mass (which can be compared with liver mass) or direct endothelial cells with a length of 7.0 km. Its area is 600.0 m² (approximately the size of a football field). The endothelium is a permeable membrane that delimits blood flow from the deep structures of vessels and directly releases a large number of very active substances, that is, is a giant paracrine organ in the human body [3, 7, 11].

It has been proved that, with hypertension, a constant increase in blood pressure is associated with vascular remodeling and structural reduction of the lumen of the arteries as a result of thickening of the medial layer [3, 7, 9].

As it is known, pressurizing agents are synthesized in the human body – endothelin, angiotensin II and thromboxane, which suppress the vasodilatory effect of the endothelial factor on the relaxation and synthesis of prostaglandins, nitric oxide (NO). Patients with acute myocardial infarction (AMI) have endothelial dysfunction in accordance with the endothelium-dependent vasodilation (EDV) test, with its further improvement under the influence of modern treatment. The greatest complications during the early post-hospital period are observed in patients with deterioration of the sample with reactive hyperemia in the dynamics of observation, multi-vascular lesions of the coronal bed [7].

In the case of AMI, endothelial dysfunction occurs according to the results of determination of endothelin-1, there is an adverse effect of post-infarction remodeling on the circulatory system with the acquired myocardial spherical shape [4]. In patients with stable angina, certain features of endothelial dysfunction, which are combined with impaired lipid metabolism and imbalance of the autonomic nervous system, with the predominance of sympathetic, and an increase in heart rate of more than 80 beats / min, have been found out [1].

Angiotensin converting enzyme (ACEI) inhibitors, angiotensin II receptor blockers, calcium antagonists are used to correct endothelial function disorders in patients with acute coronary syndrome [2, 3, 8, 9]. In unstable angina (UnA), the level of endothelin-1 changes differently: its decrease is assessed as improvement, increase – as a deterioration of endothelial function. ACEI in such patients leads to a decrease in blood content of endothelin-1, improvement of endothelial function and stabilization of atherosclerotic plaque. Absence of clinical effect and increase of blood content of endothelin-1 by UnA can be considered as a basis for stenting of coronary arteries (CA) [8].

In patients with primary and recurrent myocardial infarction, PERSPECTIVE used perindopril ACEI to stabilize atherosclerotic plaque and reduce the risk of CA thrombosis. Perindopril significantly affected myocardial remodeling during the first six months by reducing vasoconstriction and normalizing the left ventricular ejection fraction (LV) [2]. Another study confirms the ability of perindopril, regardless of its antihypertensive effect, to restore impaired endothelial function in hypertensive patients, which is realized over a relatively short period of treatment, possibly as a result of positive metabolic processes and reduced their negative effect on the vascular wall [9].

The positive effect of ACE inhibitors is explained by a decrease in the negative effect of angiotensin II on the vascular wall and an increase in the positive effect of bradykinin on the coronary and peripheral vessels [10].

The influence of basic complex treatment on the achievement of the targets of blood pressure, dynamics of shoulder artery remodeling and endothelial dysfunction in patients with AMI with comorbid hypertension have not been sufficiently studied.

The aim of the study. To determine the effectiveness of basic complex treatment in achieving the targets of blood pressure, dynamics of shoulder artery remodeling and endothelial dysfunction in patients with acute myocardial infarction with ST segment elevation with comorbid arterial hypertension for two years.

Materials and methods of research. Among men, AMI with ST segment elevation were identified in 22 (100.0 %). The mean age of the patients was 56.7 ± 1.57 years. Repeated MI was recorded in 7 (31.8 %), systolic blood pressure (SBP) was 157.8 ± 1.24 mm Hg art., diastolic blood pressure (DBP) – 96,5 ± 1,62 mm Hg art. Duration of chronic coronary heart disease 3.20 ± 0.65 years, concomitant hypertension – 8.80 ± 0.95 years. Heart failure (HF) of I – III functional classes (FC) according to the NYHA classification was determined in 22 (100.0 %). The examination did not include patients with HF IV FC, persistent atrial fibrillation, idiopathic cardiomyopathies, severe lung disease, liver, kidney, and neoplasms.

Electrocardiography, determination of troponin I, lipid spectrum were used for examination of patients. Shoulder artery Doppler ultrasound was performed using an LOGIQ 500 ultrasound diagnostic scanner (General Elactric, USA). The thickness of the intima-media complex (TIMC) of the brachial artery was measured with the determination of endothelial dysfunction and the use of a test with reactive hyperemia according to D. S. Celer – S.M. Mayer. The examination was conducted before treatment after 6, 12 and 24 months.

Standard comprehensive treatment lasted two years and included ACEI perindopril at a dose of 5.0-10.0 mg/day, b-blocker bisoprolol – 5.0-10.0 mg/day, hypolipidemic drug atorvastatin – 20.0 mg/day, acetylsalicylic acid – 75.0 mg/day.

The control group consisted of 20 patients of similar age and sex without CHD. Statistical processing was performed to determine the mean values ​​(M), the error of the mean value (m) and the presence of validity (p) according to the Student.

Results of the study and their discussion. It is known that in the course of changes in different vessels, an increase in SBP and DBP plays a major role. In patients with transferred AMI with comorbid hypertension, the target blood pressure for treatment was reached in 3 (13.0 %) patients, and in 20 (87.0 %) patients it was increased. Following standard optimal drug treatment, the achievement of BP targets was observed more frequently and after 6 months, it increased by 57.0 %, after 12 months – by 80.8 %, and after 24 months, the BP was normalized in all patients.

Therefore, the above information indicates that in patients with transmitted AMI in combination with hypertension after the optimum comprehensive two-year treatment, the target blood pressure level was reached in almost all patients, which indicates the effectiveness of antihypertensive treatment.

It is believed that in the case of a significant increase in blood pressure in patients with hypertension, the risk of coronary heart disease and stroke, which is realized through endothelial dysfunction, the basis of which is a decrease in the content of nitric oxide in the blood, increased synthesis of endothelin-1 and the expression of the surface of endothelial cells, endothelial lining integrity violation [3, 7].

In patients with coronary heart disease in combination with hypertension with frequent recurrence of atrial fibrillation significantly increases TIMC, indicating the occurrence of structural remodeling of central vessels in the group of patients with frequent recurrence of atrial fibrillation [7, 9].

Noteworthy is the study of the degree of remodeling of the brachial artery in the examined patients. Dynamics of indicators of humeral artery remodeling in the examined patients after two years of treatment are shown in Table. 1.

Table 1

Shoulder artery remodeling and endothelial dysfunction in patients with acute myocardial infarction in combination with hypertension before and after basic complex treatment

Notes: # p < 0.05, p < 0.001 – comparison of study results after 6, 12 and 24 months with results before treatment; * p < 0.05; p < 0.001 – comparison before and after 6, 12 and 24 months. after treatment with the results of the control group.

In the examined patients (Table 1) before treatment, a significant increase in the TIMC of the brachial artery (p < 0.01), a decrease in the EDVD were determined, indicating the presence of brachial artery hypertrophy and endothelial dysfunction. The revealed remodeling of the brachial artery is caused by neurohumoral disorders, an increase in SBP and DBP. After standard two-year treatment, the examined patients recorded positive reliable dynamics of TIMC, EDVD, which indicate positive dynamics of remodeling of the brachial artery and restoration of endothelial function. It is believed that an important place among antihypertensive drugs that affect the normalization of vascular endothelial function, ACEI [7, 8].

Therefore, vascular remodeling and endothelial dysfunction are two sides of the same process associated with each other. Thickening of the complex of the intima-media of the brachial artery and the occurrence of endothelial dysfunction are considered as an early and very sensitive sign of atherosclerosis. At the same time, the enlargement of the TIMC of the brachial artery correlates positively with the condition of its EDVD.

The criteria for the degree of humeral artery hypertrophy in the case of cardiovascular disease (CVD) were evaluated according to the declarative patent O.V. Denesyuk et al., 2013 [5]. According to the criteria of the degree of humeral artery hypertrophy in patients with coronary artery disease in combination with hypertension, the first (initial) degree of TIMC is 0.910 ± 0.009 mm, the second (moderate) degree is 0.96 ± 1.01 mm, the third (significant) degree is 1.010 ± 0.009 mm (for norms 0.85 ± 0.003).

The results of the study of the dynamics of degrees of humeral artery hypertrophy in patients with AMI after treatment are given in table 2.

Table 2

Dynamics of degrees of humeral artery hypertrophy according to information of intima-media thickness in patients with acute myocardial infarction in combination with arterial hypertension after basic complex two-year treatment

The results of the table 2 indicate that before treatment I (initial) degree of humeral artery hypertrophy was recorded in 12 (54.5 %) patients, II (moderate) – in 4 (18.2 %), III (significant) – not fixed.

In the examined patients, the III (significant) degree of hypertrophy of the brachial artery was not recorded either before or after the treatment. II (moderate) degree of humeral artery hypertrophy, despite the small number of patients, tended to decrease by 9.1 %. And (initial) degree of humeral artery hypertrophy varied in different directions: after 6 months it decreased by 29.5 %, and after 12 and 24 months increased by 8.0 and 9.1 %.

Some changes occurred in the endothelial function of the examined patients. We have proposed criteria for the diagnosis of endothelial dysfunction in the case of CCA [5]. The criteria for the diagnosis of the degree of endothelial dysfunction of the brachial artery are as follows: the endothelial function of the arteries is normal in the case of an increase of the EDV after the test for hyperemia by 10.0 % or more, and the (initial) degree is less by 5.0-9.9 %, II (moderate) degree – from 0 to 4.9 %, III (significant) degree – from 0 to a paradoxical decrease.

The dynamics of the degrees of disorders of the endothelial function of the brachial artery in patients with AMI are shown in table 3.

Table 3

Dynamics of degrees of endothelium-dependent vasodilation using a reactive hyperemia test in patients with acute myocardial infarction with comorbid arterial hypertension after optimal treatment for two years (n; %)

The following changes in the endothelial function of blood vessels were revealed in patients with the transferred AMI (Table 3) before treatment: I (initial) degree of EDVD – in 3 (13.6 %), II (moderate) – in 7 (31.8 %), III (significant) degree – in 11 (50.0 %). In these patients often a significant and moderate degree of endothelial dysfunction occurred. Following basic optimal two-year treatment, there was a tendency for a decrease in the number of III (significant) degree (9.0 %) and an increase in the number of I (initial) degree (45.5 %) due to the transition of more pronounced changes in EDVD to less pronounced ones.

Conclusions. In patients after acute myocardial infarction with comorbid arterial hypertension, the target blood pressure for treatment was 13.0 %, and after optimal two-year treatment the number of patients with it gradually increased after 6 months it was determined at 70.0 %, after 12 months – in 93.8 %, after 24 months. – in 100.0 %. The examined patients before treatment recorded a significant increase in the thickness of the intima-media complex and a decrease in endothelium-dependent vasodilation of the brachial artery, suggesting arterial remodeling and endothelial dysfunction.

For 6, 12 and 24 months after treatment, there was a tendency to improve the index of shoulder artery remodeling and endothelial dysfunction. Individual analysis of the degree of disorders of the indexes of the remodeling of the brachial artery, despite the small number of surveyed persons, showed a tendency to decrease the number of patients with II (moderate) thickness of the complex of intima-media and III (significant) degree of endothelium-dependent vasodilation. It indicates the positive dynamics of brachial artery remodeling, endothelial function, and treatment efficacy.

References

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