EFFICACY OF SPIRONOLACTONE IN ANTIHYPERTENSIVE THERAPY IN PATIENTS WITH RESISTANT HYPERTENSION IN COMBINATION WITH RHEUMATOID ARTHRITIS.

The aim of the study is to investigate the antihypertensive efficacy, structural and functional remodeling of the heart in patients with resistant hypertension (RH) and rheumatoid arthritis (RA) after 12-month of therapy. The treatment includes angiotensin-converting enzyme inhibitor, calcium channel blocker, diuretics, aldosterone receptor blocker (spironolactone), and immunosuppressive drug (methotrexate). 101 patients with hypertension (H) and RA were examined at the screening visit. 60 patients (mean age 61.9±9.1 years; 84.6% of women) meeting the criteria for RH were selected after 1 month. A randomized, controlled, parallel-group prospective study was conducted. Patients underwent general clinical, laboratory, and Doppler echocardiography investigations. They were divided into 2 groups: the main group, which represented patients whom to the basic antihypertensive therapy were added spironolactone 25 mg/day (group 1, n=30), and the comparison group, which represented patients who continued antihypertensive treatment without the addition of spironolactone (group 2, n=30) with 12- monthly observation. Groups of patients are comparable in age, sex, duration of RA and H, RA activity. The target blood pressure was achieved in 86.7% against 30.0% of patients (p <0.001) on spironolactone treatment compared to the inclusion of it. Therapy with spironolactone shown a probable decrease in the mean systolic blood pressure, diastolic blood pressure, and pulse blood pressure by 11.8%, 17.8%, and 5.4%, respectively. There was a reduction in the number of patients with left atrium dilatation from 86.7% to 63.3% (χ²=4.4, p=0.037) in group 1. The frequency of left ventricular hypertrophy (LVH) dropped by 10% (χ²=3.9, p=0.048) in patients of group 1. The incidence of eccentric LVH with left ventricular (LV) dilatation decreased by 2.2 times, concentric LVH with LV dilatation declined by 2.5 times after treatment in group 1. There was a further LV hypertensive remodeling in group 2: detection of concentric LVH without LV dilatation (χ²=3.3, p=0.04) was increased. There was a reduction of LV mass index (by 13.0%, p<0.01) due to a decrease in the stage of LV dilatation (by 7.3%, p<0.01), and the thickness of its walls (respectively interventricular septum and posterior wall by 17.3% and 15.2%, both p<0.01) in spironolactone group with the absence of probable changes in group 2. The LV contractile capacity, both regional fractional shortening and global ejection fraction improved (decline by 15.5% and 7.9% (both p<0.01)) in group 1 in the absence of dynamics in group 2. The incidence of LV diastolic dysfunction subsided from 83.3% to 40.0% (χ²=11.9, p<0.001) in patients of the spironolactone group, mainly due to a probable lessening in a number of patients with an abnormal LV relaxation from 60.0% to 36.7%. There was a lowering in E/e' med, E/e' lat and E/E' by 8.6%, 6.0% and 7.3%, respectively (all p <0.01) in patients on spironolactone therapy, which reflected the improvement of LV diastolic function. Patients of group 1 demonstrated a de-escalation of RA activity: a dropping of the DAS28-CRP from 5.6 (4.9-6.4) to 4.0 (3.4-5.0) (р<0,0001) in the absence of its dynamics in patients of group 2 (from 5.7 (5.0-6.1) to 5.6 (5.0-6.5) (p=0.6)). The addition of spironolactone to basic therapy demonstrates increased antihypertensive efficacy and potent antihypertrophic efficacy. These effects are combined with improved systolic and diastolic LV function and a decrease of clinical and laboratory activity of RA in elderly patients with RH in combination with RA.