The clinical significance of renovascular arterial hypertension is determined by it is high prevalence as well as it is negative impact on prognosis. The most common causes of renovascular arterial hypertension are atherosclerotic stenosis of the renal arteries and fibromuscular dysplasia. Renovascular arterial hypertension is characterized by the development of blood pressure resistant to antihypertensive therapy with an unfavorable prognosis of worsening renal function and cardiovascular complications. Currently, the most available screening method in the diagnosis of renovascular arterial hypertension is duplex scanning of the renal arteries. Non-invasive diagnostic methods also include magnetic resonance and multispiral computed tomography with intravenous contrast. Contrast angiography remains “the golden standard” for diagnosing renovascular arterial hypertension and determining the indications for surgical treatment. Together with the use of diagnostic techniques such as measurement of translesion pressure gradient and fractional blood flow reserve, it allows to assess the functional significance of renal artery stenosis. Treatment of renovascular arterial hypertension is a complex process aimed at normalization of blood pressure, improvement of renal function, as well as mortality and cardiovascular risk reduction. To date, the feasibility of endovascular treatment remains an open question. More often the preference is given to conservative treatment. The indications for renal artery revascularization are less obvious, available clinical guidelines and results of large trials are controversial.

The updated 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension approved new criteria for diagnosis of pulmonary hypertension (PH). In this review we present the data from modern studies proving the expediency of changing the threshold values of hemodynamic parameters measured by right heart catheterization (RHC) and echocardiography for the diagnosis of PH, the importance of introduction the definition «exercise PH» into clinical practice.

New haemodynamic definition of pulmonary arterial hypertension: mean pulmonary arterial pressure (mPAP) > 20 mmHg, pulmonary arterial wedge pressure < 15 mmHg, pulmonary vascular resistance (PVR) > 2 Wood units, measured by RHC at rest. Diagnostic levels of systolic pulmonary arterial pressure and tricuspid regurgitation velocity measured by echocardiography stay the same, but it is important to combine them with a number of additional echocardiographic signs of PH.

Promising direction for early diagnosis of PH is RHC during exercise in addition to studies at rest. Nowadays there are no generally accepted diagnostic criteria for exercise PH. Some studies propose the following threshold values of exercise PH: mPAP > 30 mmHg and PVR > 3 Wood units during exercise.

This clinical case illustrates the diagnosis of a rare congenital pathology – an adult patient with pulmonary arterial hypertension and Abernethy malformation type Ib.

Clinical observation: Patient S., 45 years old, with pulmonary arterial hypertension, was admitted with complaints of shortness of breath during intense physical exertion. Based on the anamnesis morbi, the diagnosis of idiopathic pulmonary arterial hypertension has been verified since 2017. Results of comprehensive examination: functional status (six-minute walk test), NTpro-BNP level, chest x-ray, echocardiography, right heart catheterization were assessed during the hospitalization. According to these there were signs of the high pulmonary arterial hypertension with systolic pressure in the lung arteries 68-70 mm Hg, extension of the trunk, right and left branches of the pulmonary artery. In order to exclude objective evidence of cardiac dysfunction, portal hypertension, an abdominal ultrasound was performed. We didn’t obtaine the information about an increase in central venous pressure, the presence of signs of portal hypertension, such as ascites, increased pressure in the portal system. However, echo signs of congenital pathology were determined - Abernethy malformation type Ib: porto-caval shunt between the superior mesenteric vein and the inferior vena cava. According to multispiral computed tomography of abdominal organs with contrast: the superior mesenteric vein and splenic vein join to form a short extra-hepatic portal vein which drains into a systemic vein (inferior vena cava). Taking into account the results of risk stratification, the patient underwent an escalation of pathogenetic therapy for the treatment of pulmonary arterial hypertension, and dynamic monitoring was recommended.

Conclusion: The presented clinical case is unique in terms of diagnosing a rare congenital pathology of the hepatic blood flow – Abernethy malformation type Ib in an adult patient with pulmonary arterial hypertension.

Pulmonary veno-occlusive disease (PVOD) is verified by identifying typical pathological changes in lungs or mutation in the EIF2AK4 gene. Clinical suspicion is based on combination of specific pulmonary pattern on computed tomography scan, hypoxemia with low diffusing lung capacity (DLCO) and inadequate response to specific therapy of pulmonary arterial hypertension (PAH). The rapid course of PVOD with high mortality determines the importance of early diagnosis and lung transplantation refferal.

We present an unusual clinical case of 40-year-old woman with expected idiopathic PAH and extremely low DLCO with verified EIF2AK4 gene mutation, who demonstrated a positive vasoreactive test (VRT) and clinical response to calcium channel blockers therapy at the onset of the disease. The loss of positive VRT and subsequent PAH specific therapy escalation resulted in PVOD manifestation with severe desaturation, recurrent syncope and pulmonary edema. The combination of low DLCO and inadequate response to PAH therapy in idiopathic PAH patient should be of a paramount awareness of PVOD. Careful PAH therapy escalation with meticulous follow-up, pulmonary multispiral CT and genetic testing could improve early PVOD diagnostics and lung transplantation referral.

Relevance. Anxiety-depressive disorders are a frequent companion of arterial hypertension (AH). It is known about the deterioration of the prognosis in patients with a combination of these conditions. At the same time, it is unclear whether complex antihypertensive therapy (AHT) with the inclusion of an antidepressant will improve the control of hypertension, slow down target organ damage, and whether it will be equally effective in men and women.

The aim of the study – identify gender characteristics of the structural and functional state of the myocardium of the left ventricle (LV) and the effect of antihypertensive therapy with and without the inclusion of an antidepressant on left ventricular myocardial remodeling in patients with AH and ADD, taking into account the gender of the patient.

Materials and methods. The study included 182 patients: 62 with AH (32 men and 30 women) and 120 – with AH and anxiety-depressive disorders (30 men – group 1, 30 women – group 2). Patients with AH and anxiety-depressive disorders were randomized into 2 subgroups (A and B). Patients of subgroup A received a fixed combination of an angiotensin II receptor blocker and a diuretic, a beta-blocker and an antidepressant, patients of subgroup B received similar antihypertensive therapy without including an antidepressant. All patients at inclusion in the study and after 24 weeks underwent a general clinical examination, office measurement of blood pressure (also after 4,8,12 weeks), 24-hour blood pressure monitoring, echocardiography, testing on the HADS, CES-D scales, and a psychiatrist's consultation.

Results. Men and women with AH and anxiety-depressive disorders, the negative changes in the main parameters of the LV structural and functional state were more significant than in patients with a normal psychoemotional status. At the same time, in women with anxiety-depressive disorders, LV hypertrophy (LVH) was more pronounced than in men. Target levels of blood pressure were achieved faster in the groups treated with antidepressant, however, intergroup differences reached the level of statistical significance only in women. Complex pharmacotherapy led to a more significant improvement in LV structural and functional state than traditional AHT, especially in women. The use of an antidepressant led to a reduction in anxiety and depressive symptoms, which was not observed in patients only with AHT groups.

Conclusions. Patients with AH and anxiety-depressive disorders develop more pronounced remodeling of the LV myocardium than patients with AH with a normal psychoemotional status, especially in women. The combined use of sertraline and antihypertensive drugs contributes to a more rapid achievement target levels of blood pressure, a significant improvement in LV structural and functional state, which is more pronounced in women than in men. It is also important to normalize the psycho-emotional status against the background of an integrated approach to the pharmacotherapy of patients with AH and anxiety-depressive disorders.

In April 2023, a well-known scientist, a remarkable clinician, a representative of the best traditions of the Moscow and Russian therapeutic schools, Professor Valery I. Podzolkov, celebrated his anniversary.