RU2542462C2 - Method for correction of crisis course of hypertensive disease and abdominal obesity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to therapy and endocrinology, and concerns the correction of the crisis course of hypertensive disease and abdominal obesity. To this effect, Moxogamma 200-400 mcg/day and Reduxin 18-30 mg/day are administered with underlying a therapy of the angiotensin converting enzyme inhibitor lisinopril. The preparations are administered in two stages - in the morning and 6 or 7 hours later; Moxogamma is first to be administered, and Reduxin is administered 40-60 min later.

EFFECT: method provides decreasing systolic and diastolic pressure, reducing the signs of cardiac failure and correcting the metabolic disorders by improving the endothelial function, reducing the sympathetic activity and the insulin resistance.

12 tbl, 2 ex

Description

The invention relates to medicine and can be used as a method of correction of the crisis course of hypertension and abdominal obesity.

A known method of detoxification of the body using plasmapheresis (1 - ed. Certificate. N 1659058, MKI A61M 1/36). This method is taken as an analog.

There is also known a method of treating the metabolic syndrome, including the introduction of captopril, characterized in that this introduction is combined with the intake of mineral water “Dzhemuhskaya 1-T” (2 - RF patent No. 2132190, MKI 6 A61B 5/02, 1997). This method is adopted as a prototype.

The disadvantage of the prototype method is the relatively limited effectiveness of the therapy of the crisis course of hypertension and abdominal obesity.

The aim of the invention is to increase the effectiveness of therapy for the crisis course of hypertension and abdominal obesity.

The technical result is achieved by the fact that moxogamma at a dose of 200-400 mcg / day and reduxin at a dose of 18-30 mg / day, divided into two doses in the morning and after 6-7 hours, are additionally used as drugs, and Moxogamma is first used with subsequent administration of reduxin after 40-60 minutes.

The method is implemented as follows.

Middle-aged patients, leading a sedentary lifestyle at the computer and constantly driving in a company car. Over the past 5-7 years, they suffer from hypertension, which manifests itself initially as a periodic increase in blood pressure from 120/70 to 160/100 mm Hg. against the background of psychoemotional stress and a gradual increase in weight by 10-15 kg. The waist circumference is 140-160 cm. Hypertension takes on the character of a crisis course with a periodic rise in blood pressure to 220 / 130-140. Pulse 80-92 beats per minute. On the ECG, signs of left ventricular hypertrophy. Decreased glucose tolerance.

Patients are treated with a diagnosis of stage II-III hypertension, moderate, moderate risk, refractory to antihypertensive therapy (enap, atenolol, amlodipine). Frequent supraventricular extrasystole. Obesity I-III degree. Impaired carbohydrate tolerance. Metabolic syndrome. Non-alcoholic fatty liver disease in the stage of steatohepatitis, a moderate degree of activity.

Objectively upon admission: satisfactory condition, hypersthenic physique. The skin is of normal color, the face is hyperemic, the visible mucous membranes are subicteric. Slight pastiness of legs, feet. In the lungs, vesicular breathing, side breathing noises are not heard. BH 17-19 in a minute. Heart sounds are muffled, the rhythm is correct. Heart rate - 80-92 per minute. HELL 170-180 / 90-100 mm Hg The tongue is densely lined with white-yellow bloom. The abdomen is enlarged due to subcutaneous fat, soft, sensitive in the right hypochondrium. There are no peritoneal symptoms. The liver + 3-4 cm, the spleen is not palpable. The symptom of "striking" is negative on both sides.

Examination:

ECG: sinus rhythm, single supraventricular extrasystoles. Signs of moderate left ventricular hypertrophy. Slight depression of the RS-T segment to 0.3-0.5 mm in leads U _5-6 .

Echocardiography: an increase in AND LVM (130-135 g / m ² ), And CSR (31-33 g / m ² ), 2H / D, OPSS (1610-1880 days × s / cm ⁵ ), signs of LV diastolic dysfunction I type (E / A - 0.88-0.98). PV - 53-56%.

Daily monitoring of blood pressure: There is an increase in SBP, DBP, a significant increase in the time index of SBP and DBP, a moderate increase in the variability of blood pressure and a low degree of nightly decrease in blood pressure. The daily profile of blood pressure as a non dipper.

Heart rate variability: there is a significant decrease in heart rate variability (HRV) due to a decrease in SDNN, SDANN, SDNN ind, and markers of parasympathetic activity (rMSSD and pNN50) and circadian index (CI). Indirect signs of an imbalance in both parts of the autonomic nervous system (ANS) with hyperactivation of the sympathetic link and a decrease in the activity of the parasympathetic link of the system.

The study of changes in the diameter of the brachial artery (ΔD ₂ ) when creating reactive hyperemia during a cuff test: revealed III degree.

Holter ECG monitoring showed a significant number of supraventricular extrasystoles.

Ultrasound of the abdomen: The liver is enlarged. The structure of the parenchyma is heterogeneous. Echogenicity is increased. The vascular pattern is significantly depleted. The portal vein is not dilated. There are no volume formations. Bile ducts up to 1 cm. There are no stones. There are no additional entities. The gall bladder is moderately enlarged, the walls are thickened. Content is biliary sludge. The paravesical region is not changed. The pancreas is located usually. The head is enlarged. The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased. Wirsung duct is not expanded. The contours of the spleen are even, clear, the capsule is not changed. The parenchyma is homogeneous. Echogenicity is average. The splenic vein is not dilated. Loops of the intestines are not expanded. Conclusion: Enlarged and diffuse changes in the liver. Diffuse changes in the pancreas (chronic pancreatitis).

Endoscopy: The endoscope is freely held in the stomach. The lumen of the esophagus is not deformed; when insufflated with air, it straightens well. The mucous membrane of the esophagus is pink, smooth, shiny. The socket of the cardia closes periodically. The lumen of the stomach is not deformed, with insufflation with air it is easily straightened. In the stomach lumen on an empty stomach, a moderate amount of fluid mixed with mucus. The gastric mucosa is moderately hyperemic in the body along the tops of the folds, in the antrum it has a spotty appearance. Multiple xanthomas from 0.3 to 0.5 cm are visualized in the body and in the antrum of the stomach. Peristalsis is satisfactory, symmetrical. The gatekeeper is round, spasmodic, we pass. Bulb of the duodenum of medium size, mucous pale pink, in the lumen of bile. Postbulbar departments: 12pc mucosa pale pink, active motility, large duodenal papilla - in a typical place, without features. Conclusion: Multiple xanthomas of the stomach. The spasm of the pylorus.

Abdominal Doppler ultrasonography: Forming portal hypertension.

Chest x-ray: The lungs are emphysematous, without foci and infiltrates. Pulmonary pattern can be traced to the edges of the fields. Mooring overlays in the anterior part of the rib-phrenic sinus on the left. The roots are differentiated. The contours of the diaphragm are smooth. The aorta is sealed. A heart of ordinary size and shape. Conclusion: age-related pulmonary emphysema, aortocardiosclerosis.

X-ray examination of the upper gastrointestinal tract: Esophagus and cardia passable. The abdominal esophagus prolapses into the mediastinum. The stomach is usually located. Normotonic. Fasting fluid. Edematous mucosa is represented by convoluted longitudinal folds. With tight filling, the contours are smooth. Peristalsis can be traced in all departments. Evacuation function is not impaired. The duodenal bulb of normal size. Its mucosa and proximal half of the slightly expanded duodenum are slightly swollen. Passage of barium suspension along the proximal loops of the jejunum is not impaired. Conclusion: A hiatal hernia. Gastroduodenitis. Signs of chronic pancreatitis.

In patients with morbid obesity, non-alcoholic fatty liver disease occurs in the stage of steatohepatitis (mixed genesis: dysmetabolic and drug - statin). Given the pronounced cytolytic component, dyslipidemia with a high coronary risk (in the history of acute myocardial infarction), the appointment of lipid-lowering therapy in combination with hepatoprotectors is necessary.

Puncture biopsy of the liver: Portal tracts are enlarged, moderately infiltrated by lymphocytes and moderately fibrosed. Connective tissue septa connect adjacent portal tracts. Follicle-like accumulations of lymphocytes and sections of ductal hyperplasia in individual tract tract portal tracts. In some portal tracts, the integrity of the border plate is impaired and lymphocytic infiltrate spreads between the hepatocytes deep into the lobules. Large-drop fatty infiltration of hepatocytes. Steatosis Index - 1. Severe cell hyperplasia of the reticuloendothelial system. Conclusion: Chronic portal and periportal hepatitis of moderate degree of activity. Patients are treated according to the following scheme:

Stage 1: 3 weeks - lisinopril at a dose of 10 mg per day 1 time in the morning

2nd stage: 3 weeks - lisinopril (diroton) 10 mg / day + Moxonidine at a dose of 0.2-0.4 mg / day in 2 divided doses

3rd stage: 6 months, lisinopril (diroton) 10 mg / day + Moxonidine (MOXOGAMMA® from Vervag Pharm, Germany) at a dose of 200-400 mcg / day in 2 doses + reduxin 18-30 mg / day, with reduxin used two doses in the morning and after 6-7 hours, with the first use of moxogamma with subsequent administration of reduxin after 40-60 minutes.

Within 2 weeks, blood pressure decreased to 130/90 mm Hg. After 4 weeks of drug therapy, blood pressure decreased to 125/80 mmHg, pulse and heart rate 66-72 beats per minute. Within 2 years, blood pressure stabilized within normal limits - 120-140 / 80-90 mm Hg; weight decreased by 10-12 kg due to modification of eating behavior.

Patients are discharged in satisfactory condition. Subsequent follow-up observation of the liver with ultrasound is more homogeneous, the level of ALT and ACT corresponds to the norm.

The method is confirmed by the following examples.

Example 1

Patient K., 52 years old.

Clinical diagnosis: Stage II hypertension, moderate, moderate risk, refractory to antihypertensive therapy (enap, atenolol, amlodipine). Frequent supraventricular extrasystole. Obesity I degree. Impaired carbohydrate tolerance. Postmenopausal period (3 years).

For 4 years suffering from hypertension. Over the past 2 years, he has noted frequent hypertensive crises - episodes of a sudden rise in blood pressure to 170 / 95-100 mm Hg, accompanied by severe headache, dizziness, nausea, and flickering of “flies” in front of the eyes. Typically, crises stop after the treatment of emergency doctors. He regularly takes enap (10 mg / day) or amlodipine (5 mg / day), atenolol (25 mg / day). The last episode of a sharp rise in blood pressure notes 3 weeks ago, when blood pressure increased to 200/105 mm Hg, a severe headache in the occipital region, dizziness, nausea, and a single vomiting appeared. Hospitalized with a diagnosis of stage II hypertension, uncomplicated hypertensive crisis (blood pressure - 200/105 mm Hg). The crisis was stopped after injection of magnesia sulfate and the use of capoten. Within 1.5 weeks it was treated and examined in the therapeutic department. After discharge from the hospital, despite taking enap, atenolol and hypothiazide (25 mg / day), he noted frequent headaches, fatigue, an almost constant increase in blood pressure to 170 / 95-100 mm Hg, shortness of breath with little physical exertion appeared.

Re-hospitalized for examination and selection of antihypertensive therapy.

Objectively: The condition is satisfactory.

Patient with increased nutrition (BMI - 31.4 kg / m ² ). There is a slight pastiness of the feet. In the lungs, vesicular breathing, no wheezing. The borders of the heart are extended to the left. I cardiac sound is muffled on Veruska, II accent is on the aorta. Short systolic murmur at the apex. HELL - 156/94 mm Hg Pulse 86 beats / min, good filling and tension, rhythmic. The abdomen is enlarged due to subcutaneous fat, painless in all departments. The liver is 1 cm below the costal arch (percussion).

Laboratory and instrumental data:

ECG12: sinus rhythm, single supraventricular extrasystoles. Signs of moderate left ventricular hypertrophy. Slight depression of the RS-T segment to 0.5 mm in leads U _5-6 .

Echocardiography (see table. 1): there is an increase in AND MMVL (133 g / m ² ), And CSR (32 g / m ² ), 2H / D, OPSS (1612 days × s / cm ⁵ ), signs of LV diastolic dysfunction Type I (E / A - 0.97). PV - 56%.

Daily monitoring of blood pressure (table. 2): There is an increase in SBP, DBP, a significant increase in the time index of SBP and DBP, a moderate increase in the variability of blood pressure and a low degree of nighttime decrease in blood pressure. The daily profile of blood pressure as a non dipper.

Heart rate variability (Table 3): there is a significant decrease in heart rate variability (HRV) due to a decrease in SDNN, SDANN, SDNN ind, and markers of parasympathetic activity (rMSSD and pNN50) and circadian index (CI). Indirect signs of an imbalance in both parts of the autonomic nervous system (ANS) with hyperactivation of the sympathetic link and a decrease in the activity of the parasympathetic link of the system.

The study of changes in the diameter of the brachial artery (ΔD ₂ ) when creating reactive hyperemia during a cuff test: revealed III degree (table. 4).

Holter ECG monitoring showed a significant number of supraventricular extrasystoles (Table 5).

Ultrasound of the abdomen: The liver is enlarged. The structure of the parenchyma is heterogeneous. Echogenicity is increased. The vascular pattern is significantly depleted. Portal vein 7.5 mm. There are no volume formations. Bile ducts 8 mm. There are no calculi. There are no additional entities. The gall bladder is moderately enlarged, the walls are thickened to 3.5 mm. Content is biliary sludge. The paravesical region is not changed. The pancreas is located usually. The head is enlarged. The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased. Wirsung duct is not expanded. The contours of the spleen are even, clear, the capsule is not changed. The parenchyma is homogeneous. Echogenicity is average. The splenic vein is not dilated. Loops of the intestines are not expanded. Conclusion: Enlarged and diffuse changes in the liver. Diffuse changes in the pancreas (chronic pancreatitis).

Endoscopy: The endoscope is freely held in the stomach. The lumen of the esophagus is not deformed; when insufflated with air, it straightens well. The mucous membrane of the esophagus is pink, smooth, shiny. The socket of the cardia closes periodically. The lumen of the stomach is not deformed, with insufflation with air it is easily straightened. In the stomach lumen on an empty stomach, a moderate amount of fluid mixed with mucus. The gastric mucosa is moderately hyperemic in the body along the tops of the folds, in the antrum it has a spotty appearance. 0.3 cm xanthomas are visualized in the body and in the antrum of the stomach. Peristalsis is satisfactory, symmetrical. The gatekeeper is round, spasmodic, we pass. Bulb of the duodenum of medium size, mucous pale pink, in the lumen of bile. Postbulbar departments: 12pc mucosa pale pink, active motility, large duodenal papilla - in a typical place, without features. Conclusion: Multiple xanthomas of the stomach. The spasm of the pylorus.

Abdominal Doppler ultrasonography: Forming portal hypertension.

Chest x-ray: The lungs are emphysematous, without foci and infiltrates. Pulmonary pattern can be traced to the edges of the fields. Mooring overlays in the anterior part of the rib-phrenic sinus on the left. The roots are differentiated. The contours of the diaphragm are smooth. The aorta is sealed. A heart of ordinary size and shape. Conclusion: age-related pulmonary emphysema, aortocardiosclerosis.

X-ray examination of the upper gastrointestinal tract: Esophagus and cardia passable. The abdominal esophagus prolapses into the mediastinum. The stomach is usually located. Normotonic. An empty stomach contains fluid. Edematous mucosa is represented by convoluted longitudinal folds. With tight filling, the contours are smooth. Peristalsis can be traced in all departments. Evacuation function is not impaired. The duodenal bulb of normal size. Its mucosa and proximal half of the slightly expanded duodenum are slightly swollen. Passage of barium suspension along the proximal loops of the jejunum is not impaired. Conclusion: A hiatal hernia. Gastroduodenitis. Signs of chronic pancreatitis.

A patient with morbid obesity has a non-alcoholic fatty liver disease in the stage of steatohepatitis of mixed origin. Given the pronounced cytolytic component, dyslipidemia with high coronary risk, the appointment of lipid-lowering therapy in combination with hepatoprotectors is necessary.

Puncture biopsy of the liver: Portal tracts are enlarged, moderately infiltrated by lymphocytes and moderately fibrosed. Connective tissue septa connect adjacent portal tracts. Follicle-like accumulations of lymphocytes and sections of ductal hyperplasia in individual tract tract portal tracts. In some portal tracts, the integrity of the border plate is impaired and lymphocytic infiltrate spreads between the hepatocytes deep into the lobules. Large-drop fatty infiltration of hepatocytes. Steatosis Index - 1. Severe cell hyperplasia of the reticuloendothelial system. Conclusion: Chronic portal and periportal hepatitis of moderate degree of activity.

The patient is prescribed lisinopril at a dose of 10 mg / day, moxogamma at a dose of 400 mcg / day and reduxin at a dose of 18 mg / day, divided into two doses in the morning and after 6-7 hours, and at first, moxogamma is used, followed by 40- 60 min reduxin.

Within 2 weeks, blood pressure decreased to 130/90 mm Hg. After 4 weeks of drug therapy, blood pressure decreased to 125/80 mmHg, pulse and heart rate 66-72 beats per minute. Within 2 years, blood pressure stabilized within normal limits - 120-140 / 80-90 mm Hg; weight decreased by 10-12 kg due to modification of eating behavior.

Patients are discharged in satisfactory condition. Subsequent follow-up observation of the liver with ultrasound is more homogeneous, the level of ALT and ACT corresponds to the norm.

Biochemical analysis of blood: an increase in the content of triglycerides (TG), LDL cholesterol and a decrease in HDL cholesterol, as well as impaired carbohydrate tolerance (fasting glucose level of 6.1 mmol / l).

Treatment: 1st stage: 3 weeks - lisinopril (DIROTON® Hungary) at a dose of 10 mg per day 1 time in the morning;

2nd stage: 3 weeks - lisinopril (diroton) 10 mg / day + Moxonidine (MOXOGAMMA ^® from Vervag Pharm, Germany) at a dose of 0.4 mg / day in 2 divided doses

Stage 3: 6 months lisinopril (diroton) 10 mg / day + Moxonidine (MOXOGAMMA ^® from Vervag Pharm, Germany) at a dose of 0.4 mg / day in 2 doses + reduxin 18 mg / day, with reduxin used in two doses in the morning hours and after 6-7 hours, with the first use of moxogamma with subsequent administration of reduxin after 40-60 minutes.

Treatment results

Stage 1: against the background of three-week therapy with lisinopril, a tendency to normalize blood pressure (144/86 mm Hg) was noted, although the target level of blood pressure (less than 140/85 mm Hg) could not be achieved. The values of the IW SBP and IW DBP decreased (to 49-39%). The variability of blood pressure and the degree of nighttime decrease in blood pressure remained virtually unchanged. Headaches, shortness of breath decreased, and episodes of a rise in blood pressure to 160/95 mm Hg are less common. In the analysis of HRV, there was a tendency to a slight decrease in hyperactivation of the sympathetic link of the ANS, but the markers of parasympathetic activity remained practically unchanged. The number of supraventricular and extrasystoles decreased almost 2 times. However, the reaction of the brachial artery to the creation of reactive hyperemia has changed little. The levels of TG, LDL cholesterol, HDL, and fasting glucose also did not change.

2nd stage: against the background of three-week therapy with lisinopril + moxogamma, the target value of SBP and DBP was achieved, the values of SBP and SBP DB decreased significantly, the degree of night-time decrease in SBP and DBP significantly increased, and a distinct tendency to decrease in blood pressure variability was revealed. The patient's well-being improved, episodes of blood pressure rises to 160/95 mm Hg stopped. At the same time, the HRV increased significantly, and the markers of parasympathetic activity increased and the tension of the sympathetic link of the ANS decreased, the circadian index significantly increased. The number of supraventricular extrasystoles significantly decreased. At the same time, a distinct improvement in endothelial function was observed (the 1st degree of endothelial dysfunction was achieved). There has been a trend towards increased HDL cholesterol and a decrease in fasting glucose.

Stage 3: against the background of long-term therapy with lisinopril, moxogamma, and reduxin, the target values of the SBP and DBP were preserved, the values of the SBP and SBP DB decreased significantly, and the degree of night-time decrease in blood pressure normalized. There was a further decrease in sympathetic activity and a compensatory increase in markers of parasympathetic activity remained. An almost complete normalization of endothelial function has occurred. A decrease in fasting glycemia and an improvement in the lipid profile were observed. According to echocardiography, there was a decrease in LVM, end-systolic and end-diastolic LV volumes, a significant decrease in OPSS, a significant improvement in LV diastolic function. BMI decreased (BMI - 28.3 kg / m ² against the initial 31.4 kg / m ² ).

Conclusion: Combination therapy with lisinopril and moxogamma (both 3-week and 6-month-old with the addition of reduxin) in a patient with stage II hypertension refractory to previous enap and atenolol therapy and obesity demonstrated the significant advantages of this therapy over lisinopril monotherapy. This is primarily due to the positive effect of moxogamma on endothelial function, probably due to a decrease in insulin resistance, as well as a decrease in sympathetic activity, which led to a marked decrease in OPSS and an improvement in LV diastolic function. The modification of eating behavior was carried out due to the introduction of lisinopril, moxogamma, and reduxin. An important consequence of the treatment was a tendency to improve the lipid profile and decrease fasting glycemia. As a result, after 6 months of treatment, there was a reverse development of LV hypertrophy and a decrease in its systolic and diastolic sizes.

Example 2

Patient A., 58 years old.

Clinical diagnosis: Stage III hypertension, moderate, high risk, refractory to antihypertensive therapy (renitec, atenolol, sometimes hypothiazide. Corinfarum). CHD: angina pectoris II FC, frequent ventricular extrasystole. CHF II FC by NYHA. Obesity II degree. Impaired carbohydrate tolerance. Postmenopausal period (8 years).

Within 9-10 years, he noted an increase in blood pressure, he rarely consulted doctors, took "some" pills occasionally with an increase in blood pressure to 180-190 / 100-110 mm Hg. About 2 years ago, she began to notice shortness of breath with physical exertion, swelling on her legs, periodically - pain in the heart. Over the past year, the condition worsened, she was hospitalized twice with a diagnosis of hypertensive crisis, the last time - about 3 weeks ago. According to the patient, after the last discharge from the hospital, she began to systematically take renitec, atenolol, sometimes hypothiazide, corinfar and panangin. However, improvement according to the patient did not occur. According to the patient, the blood pressure did not decrease below 165/100 mm Hg, 1-2 times a week there was a rise in blood pressure to 200/110 mm Hg. The purpose of this hospitalization was the need for examination and selection of antihypertensive therapy.

Upon admission, he complains of strong, almost constant headaches, shortness of breath, swelling of the legs, weakness, pain in the heart.

Objective: The state of moderate severity. Patient with increased nutrition (BMI - 33.2 kg / m ² ). Revealed moderate swelling of the legs and feet. In the lungs, vesicular breathing is slightly weakened in the lower sections. A moderate amount of moist fine-bubbling rales is also heard there. The borders of the heart are extended to the left. The I heart tone is muffled on a Veruska, the expressed accent of the II tone on an aorta. Systolic murmur at the apex. HELL - 184/106 mm Hg Pulse 90 beats / min, good filling and tension, extrasystoles are determined up to 3-5 per min. The abdomen is enlarged due to subcutaneous fat, somewhat painful in the right hypochondrium. The liver is 2 cm below the costal arch, painful on palpation, dense-elastic consistency.

Laboratory and instrumental data:

ECG: against the background of sinus rhythm, single ventricular extrasystoles are determined. Signs of LVH, blockade of the left anterior branch of the bundle of His. Depression of the RS-T segment up to 1.0 mm in leads U _{4-6 is detected} .

Echocardiography (see table. 1): there is a significant increase in AND MMVL (133 g / m ² ), And BWW (76 ml / m ² ), And KSO (32 ml / m ² ), 2H / D (0.44) , OPSS (1875 days × s / cm ⁵ ), signs of severe diastolic dysfunction of the left ventricle type 1 (E / A - 0.89), PV 53%.

Daily monitoring of blood pressure (Table 2): There is a significant increase in SBP, DBP, time index of SBP and DBP, a moderate increase in blood pressure variability and a low degree of night-time decrease in blood pressure. The daily profile of blood pressure as a non dipper.

Heart rate variability (Table 3): there is a significant decrease in heart rate variability (HRV) due to both a decrease in SDNN, SDANN, SDNN ind, and markers of parasympathetic activity (rMSSD and pNN50), as well as circadian index (CI). Indirect signs of an imbalance in both parts of the autonomic nervous system (ANS) with hyperactivation of the sympathetic link and a decrease in the activity of the parasympathetic link of the system are more pronounced than in the previous example.

The study of changes in the diameter of the brachial artery (ΔD ₂ ) when creating reactive hyperemia during a cuff test: revealed the IV degree of endothelial dysfunction (table. 4).

Holter ECG monitoring showed a significant number of ventricular extrasystoles, per day - 456 (Table 5), episodes of depression of the RS-T segment up to 1.5 mm, in total - 48 minutes per day.

Ultrasound of the abdomen: The liver is enlarged. The structure of the parenchyma is heterogeneous. Echogenicity is increased. The vascular pattern is significantly depleted. The portal vein is not dilated (6 mm). There are no volume formations. Bile ducts up to 1 cm. There are no stones. There are no additional entities. The gall bladder is moderately enlarged, 9.6 × 7.2 cm, the walls are thickened. Content is biliary sludge. The paravesical region is not changed. The pancreas is located usually. The head is enlarged. The contours are uneven, fuzzy. The structure of the parenchyma is heterogeneous. Echogenicity is increased. Wirsung duct is not expanded. The contours of the spleen are even, clear, the capsule is not changed. The parenchyma is homogeneous. Echogenicity is average. The splenic vein is not dilated. Loops of the intestines are not expanded. Conclusion: Enlarged and diffuse changes in the liver. Diffuse changes in the pancreas (chronic pancreatitis).

EGDS: The lumen of the esophagus is not deformed, when insufflated with air, it straightens well. The mucous membrane of the esophagus is pink, smooth, shiny. The socket of the cardia closes periodically. The lumen of the stomach is not deformed. In the stomach lumen on an empty stomach, a moderate amount of fluid mixed with mucus. The gastric mucosa is moderately hyperemic in the body along the tops of the folds, in the antrum it has a spotty appearance. Multiple xanthomas 0.5 cm in diameter are visualized in the body and in the antrum of the stomach. Peristalsis is satisfactory, symmetrical. The gatekeeper is spasmodic. Bulb of the duodenum of medium size, mucous pale pink, in the lumen of bile. Postbulbar sections: the mucous membrane of the duodenum is pale pink, active motility, a large duodenal papilla - in a typical place, without features. Conclusion: Multiple xanthomas of the stomach. The spasm of the pylorus.

Abdominal Doppler ultrasonography: Forming portal hypertension.

Chest x-ray: The lungs are emphysematous, without foci and infiltrates. Pulmonary pattern can be traced to the edges of the fields. The roots are differentiated. The contours of the diaphragm are smooth. The aorta is sealed. A heart of ordinary size and shape. Conclusion: age-related pulmonary emphysema, aortocardiosclerosis.

X-ray examination of the upper gastrointestinal tract: Esophagus and cardia passable. The abdominal esophagus prolapses into the mediastinum. The stomach is usually located, normotonic, on an empty stomach contains fluid. The edematous mucosa has crimped longitudinal folds. With tight filling, the contours are smooth. Peristalsis can be traced in all departments. Evacuation function is not impaired. The duodenal bulb of normal size. Its mucosa and proximal half of the slightly expanded duodenum are slightly swollen. Conclusion: A hiatal hernia. Gastroduodenitis. Signs of chronic pancreatitis.

Puncture biopsy of the liver: Portal tracts are enlarged, moderately infiltrated by lymphocytes and moderately fibrosed. Connective tissue septa connect adjacent portal tracts. Accumulations of lymphocytes and sections of ductular hyperplasia in individual tract tract portal tracts are noted. In some portal tracts, the integrity of the border plate is impaired and lymphocytic infiltrate spreads between the hepatocytes deep into the lobules. Large-drop fatty infiltration of hepatocytes. Steatosis Index - 2. Severe cell hyperplasia of the reticuloendothelial system. Conclusion: Chronic portal and periportal hepatitis of moderate degree of activity.

Biochemical blood test: an increase in the content of triglycerides (TG), LDL cholesterol and a significant decrease in HDL cholesterol, as well as impaired carbohydrate tolerance (fasting glucose level of 6.8 mmol / l).

Treatment:

Stage 1: 3 weeks - lisinopril at a dose of 10 mg per day 1 time in the morning

2nd stage: 3 weeks - lisinopril (diroton) 10 mg / day + Moxonidine at a dose of 0.4 mg / day in 2 divided doses

Stage 3: 6 months lisinopril (diroton) 10 mg / day + Moxonidine (MOKSOGAMMA ^® company Vervag Pharma, Germany) at a dose of 200 mg / day in 2 divided doses + Reduxine 30 mg / day, and Reduxine applied in two steps in the morning hours and after 6-7 hours, with the first use of moxogamma with subsequent administration of reduxin after 40-60 minutes.

Treatment results

Stage 1: against the background of three-week therapy with lisinopril, a slightly pronounced tendency to a decrease in blood pressure was noted (175/94 mm Hg versus 184/106 mm Hg initially). The values of ABP MAP and IV DAD slightly decreased (up to 69-81%). The variability of blood pressure and the degree of nighttime decrease in blood pressure remained practically unchanged. Headaches, shortness of breath somewhat decreased. In the analysis of HRV, there was a tendency to a slight decrease in hyperactivation of the sympathetic link of the ANS (by 9-10%) and markers of parasympathetic activity. Although the circadian index (CI) has not changed. The number of ventricular extrasystoles decreased slightly. However, the reaction of the brachial artery to the creation of reactive hyperemia has changed little. The levels of TG, LDL cholesterol, HDL, and fasting glucose also did not change.

Stage 2: against a background of three-week therapy with lisinopril + moxogamma, a more pronounced decrease in SBP and DBP (164/90 mm Hg) was observed, although the target value of blood pressure (140/90 mm Hg) was not achieved. There was also a more pronounced decrease in the ABP of the SBP and the IBP of the DBP (52-60%), the values of the variability of blood pressure slightly decreased, the degree of nighttime decrease in blood pressure increased. The patient's well-being somewhat improved, episodes of blood pressure rises to 190/100 mm Hg stopped, and swelling and shortness of breath significantly decreased. The HRV markedly increased, and the values of the markers of parasympathetic activity increased and the tension of the sympathetic link of the ANS decreased, and there was a tendency toward an increase in QI. The number of ventricular extrasystoles decreased almost 3 times. At the same time, there has been a tendency to a decrease in endothelial dysfunction. However, the lipid profile and fasting glucose values have not changed.

Stage 3: against the background of long-term therapy with lisinopril, moxogamma and reduxin, a marked decrease in blood pressure (152/85 mm Hg) occurred, although the target blood pressure values were not achieved. Significantly decreased the values of IW SBP and IW DBP (up to 36-38%), a further increase in the degree of nighttime decrease in blood pressure. A further decrease in sympathetic activity was observed and a compensatory increase in markers of parasympathetic activity was maintained. The signs of endothelial dysfunction decreased (to the II degree). After 6 months treatment, there was a decrease in OPSS by 15.4% and a significant improvement in LV diastolic function (18% increase in E / A). The sizes of LV, LP, cardiac output and PV changed little. MLF decreased by 5.1%. BMI decreased (BMI - 30.7 kg / m ² against the initial 33.2 kg / m ² ). Improvements in the lipid profile and fasting glucose levels did not occur.

Conclusion: Combination therapy with lisinopril and moxogamma (both 3-week and 6-month-old with the addition of reduxin) in a patient with stage III hypertension refractory to previous therapy with enap and atenolol, obesity and signs of heart failure has shown significant advantages of this therapy over monotherapy with lisinopril. This is primarily due to the positive effect of moxogamma on endothelial function, probably due to a decrease in insulin resistance, as well as a limitation of sympathetic activity, which led to a noticeable decrease in OPSS, as well as an improvement in LV diastolic function, which probably caused a significant decrease in signs of heart failure . The modification of eating behavior was carried out due to the introduction of lisinopril, moxogamma, and reduxin.

The proposed method has been the treatment of 43 patients with hypertension of the crisis during abdominal obesity. There is a decrease in body mass index and indicators of systolic and diastolic blood pressure. Patients were discharged in a state of clinical remission. During follow-up observation for 1 year there are no episodes of increased blood pressure, which could lead to a crisis course of hypertension.

Information sources

1. Auth. testimonial. N1659058, MKI A61M 1/36.

2. RF patent No. 2132190, MKI 6 AB 5/02, 1997.

Claims (1)

A method for the correction of the crisis course of hypertension and abdominal obesity, including drug therapy with lisinopril, characterized in that moxogamma at a dose of 200-400 μg / day and reduxin at a dose of 18-30 mg / day, divided into two doses, are additionally used as drugs morning hours and after 6-7 hours, with the first use of moxogamma with subsequent administration of reduxin after 40-60 minutes.