updated 8:45 AM EET, Oct 30, 2023

2020 October-December Volume 6 Issue 4

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The impact of SARS-Cov-2 infection on the renin-angiotensin-aldosterone system and its axes. Pathogenic consequences

Victor A. Voicu
Romanian Academy, Bucharest, Romania


Coronaviruses were discovered and identified after a long series of researches of variants of viruses that were responsible for the common cold, with numerous characterization attempts, being considered for some time rhinoviruses. Intracellular penetration of the virus is achieved through spike glycoproteins with the two subunits - S1 and S2. The S1 subunit binds to the angiotensin-converting enzyme 2 (ACE-2) receptor on the surface of the host cell and S2 fuses with the cell membrane. We present a synthesis of the links between the viral receptor (ACE2), the place of ACE2 in the complex of the renin-angiotensin-aldosterone system, and its axes (ACE2-Ang (1-7) AngA/alamandine/RMas, the kallikrein-kinin/RMrgD system and pathogenic consequences of viral aggression.

J Hypertens Res (2020) 6(4):99–110 [download PDF]


Treating arterial hypertension: from guidelines to physiology and back again – the issue of increased sympathetic drive

Silvia Lupu, Ioana Sus, Dan Dobreanu
Emergency Institute of Cardiovascular Diseases and Transplantation, Targu Mures, Romania
George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Targu Mures, Romania


In the era of evidence-based medicine, the current European Society of Cardiology (ESC) guidelines for the management of arterial hypertension rely on results from randomized clinical trials. The 2018 version aims to simplify the management of hypertensive patients and generally recommends the combined use of a renin-angiotensin-aldosterone system inhibitor and a calcium channel blocker or a thiazide-like diuretic as first-line therapy. Drugs targeting the increased sympathetic drive are only recommended if the combination of all three drug classes fail to provide adequate control of blood pressure values. Although beta-blockers are still prescribed in hypertensive patients who have coronary artery disease and/or heart failure, alpha-blockers are seldom used. However, the sympathetic drive is an important link in the pathophysiology of arterial hypertension, raising the question whether some patients may obtain additional benefit from sympathetic inhibition.

J Hypertens Res (2020) 6(4):111–116 [download PDF]


Hypertension and chronic obstructive pulmonary disease – current challenges during the COVID-19 pandemic

Roxana Mustafa, Alexandru Rocsoreanu, Eugen Tieranu, Oana Munteanu-Mirea, Ionut Donoiu, Octavian Istratoaie
Cardiology Department, University of Medicine and Pharmacy, Craiova, Romania


Hypertension and chronic obstructive pulmonary disease are common conditions in the adult population that have a significant impact on the quality of life, morbidity, and mortality. The SARS-CoV-2 infection has worsened the prognosis of these patients and has complicated their therapy. SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE2) as its receptor and disturbs the renin-angiotensin system in the lungs and other organs. Patients with hypertension and cardiovascular disease have an increased risk of severe COVID-19, and some data suggested that ACE inhibitors and angiotensin receptor blockers could increase this risk. Also, the benefits of inhaled corticosteroids in chronic lung disease have been challenged.

J Hypertens Res (2020) 6(4):117–121 [download PDF]


Study of beta-blocker treatment effects in diabetic hypertensive patients with different dipper profiles: is there a link with the prognosis?

Viorel Manea, Mircea Ioachim Popescu, Lavinia Pop, Calin Pop
Cardiology Department, Emergency County Hospital of Baia Mare, Baia Mare, Romania
Cardiology Department, Emergency Clinical County Hospital of Oradea, Oradea, Romania
Faculty of Medicine, University of Oradea, Oradea, Romania
Diabetes and Nutrition Department, Emergency Clinical County Hospital of Baia Mare, Baia Mare, Romania
Faculty of Medicine, Western University of Arad, Arad, Romania


Ambulatory blood pressure monitoring (ABPM) in diabetic patients (DM) with high blood pressure (HBP) is useful to show the dipping status and effectiveness of hypertensive treatment. 163 consecutive DM type 2 patients with HBP treated with beta-blockers (βB), angiotensin-converting enzyme inhibitors (ACEI), calcium channel blockers (CCB), angiotensin receptor blockers (ARB) and diuretics, were subjected to 24-hour ABPM. We assessed the BP (blood pressure) circadian variation, the variability of resting mean heart rate (MHR), and the correlations with various drug combinations. There were 55 dippers (33.75%), 79 non-dippers (48.45%), 22 reverse dippers (12.50%) and 7 extreme-dippers (4.30%). Dippers had lower medium arterial pressure (MAP) – 88.45 mmHg and MHR - 71.35 beats per minute (bpm) compared with 91.63 mmHg and 74.27 bpm found in non-dippers (p= 0.006; p=0.05). Dippers was treated with ACEI (65.46%), ARB (18.19%), CCB (40.00%), combinations of these (10.91%), βB (60.00%), and diuretics (74.55%). Non-dippers treated with βB (68.36%) had lower 24-hour MHR - 72.46 bpm vs. 78.20 bpm (p= 0.017) of those without βB, night MHR – 73.90 bpm vs. 82.02 bpm (p=0.0004) and day MHR - 74.61 bpm vs. 81.76 bpm (p=0.005). The non-dipper diabetics had increased MAP and MHR compared to dippers, but non-dippers treated with beta-blockers had significantly low MHR and MAP than those without BB. Treatment of BP with beta-blockers does not significantly influence lowering MHR and MAP in dippers profile. The effect of reducing MHR on the non-dipper profile could be beneficial for the prognosis of these patients.

J Hypertens Res (2020) 6(4):122–128 [download PDF]


Early detection of subclinical organ damage in patients with risk factors – an ongoing journey

Stefania Lucia Magda, Simona Ionela Visoiu, Laura Alexandra Mitrea, Livia Maria Radu, Roxana Cristina Rimbas, Andrea Olivia Ciobanu, Diana Janina Mihalcea, Andreea Elena Velcea, Vladimir Dan Bratu, Dragos Vinereanu
Cardiology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Cardiology Department, Emergency University Hospital of Bucharest, Bucharest, Romania


Despite the evolution of preventive therapies, cardiovascular morbidity and mortality remain high among patients with risk factors (RF) for atherosclerosis. We aimed to evaluate cardiac and vascular function parameters in patients with RF for atherosclerosis without overt vascular disease and the additional influence of diabetes on these parameters. Fifty-six subjects (60±8 years, 42 women) with RF for atherosclerosis without overt cardio-, cerebro- or peripheral artery disease were studied. Left ventricular (LV) ejection fraction, determined through standard 2D echocardiography (2DEF), and left ventricular 2D longitudinal strain (2DLS), determined through speckle tracking echocardiography, were used as markers of cardiac dysfunction. We determined the left and right ankle-brachial index (L-ABI and R-ABI, respectively) and cardiac ankle index (L-CAVI and R-CAVI, respectively), using dedicated equipment (VaSera VS-1500 Fukuda-Denshi, Japan) as markers of vascular dysfunction. The results of patients with diabetes mellitus (DM) (20 pts) were compared to those of patients without diabetes mellitus (non-DM) (36 pts). Mean values of 2DEF and 2DLS were in normal limits in all patients, without significant differences between diabetic and nondiabetic (2DLS of -19.6±3.1 in DM vs. -20.3±2.9% in non-DM, p=NS). Also, vascular function parameters were similar in both study groups (R-ABI of 1.04±0.09 in DM vs. 1.06±0.08 in non-DM, p=NS, and R-CAVI of 7.6±1.1 in DM vs. 8.5±1.5 in non DM, p=NS). Cardiac and vascular function parameters that are currently used do not signal early organ damage even when measured in asymptomatic patients, suggesting that more subtle imaging or biological detection methods should be used in populations with RF for atherosclerosis.

J Hypertens Res (2020) 6(4):129–137 [download PDF]


Aortic stenosis and difficult to treat hypertension: an impossible duo?

Madalina Badea, Ana Maria Balahura, Vlad Bataila, Costin Minoiu, Daniela Bartos, Elisabeta Badila
Cardiology Department, Elias Emergency University Hospital, Bucharest, Romania
Internal Medicine Department, Floreasca Emergency Clinic Hospital, Bucharest, Romania
Internal Medicine Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Cardiology Department, Floreasca Emergency Clinic Hospital, Bucharest, Romania
Radiology Department, Floreasca Emergency Clinic Hospital, Bucharest, Romania


An 84-year-old female patient was admitted to our clinic for progressive shortness of breath and low functional capacity for one month. She has been hypertensive for almost 30 years, currently with poor blood pressure control despite four antihypertensive drugs. There were no signs of systemic or pulmonary congestion, but a holosystolic murmur in the aortic area was present. The echocardiography revealed moderate concentric left ventricular hypertrophy and a global longitudinal strain of -14.1%, indicating subclinical longitudinal systolic dysfunction of the left ventricle but with preserved ejection fraction. The tricuspid aortic valve had important degenerative structural changes, with an indexed area of 0.55 cm2/m2 indicating severe stenosis. Abdominal contrast computed tomography revealed a small area of cortical hyperplasia in the left adrenal gland, along with calcifications of both renal arteries from their origin, resulting in 60% bilateral stenosis. The antihypertensive treatment did not provide sufficient control, with average overall values of 165/77 mmHg on 24h ambulatory blood pressure monitoring with a non-dipper pattern. Thus, a diagnosis of grade 3 stage 3 arterial hypertension was established in a patient recently diagnosed with severe degenerative aortic stenosis. We reckon that the cause of the inadequate blood pressure control included the combination of suboptimal treatment selection and titration, along with persistent causes of hypertension such as atherosclerotic renovascular disease, sleep apnoea and possibly primary hyperaldosteronism. The optimal treatment approach combined reinforcement of lifestyle measures with antihypertensive drugs, considering all medication classes, including blockers of the renin-angiotensin-aldosterone system, despite the presence of severe aortic stenosis.

J Hypertens Res (2020) 6(4):138–144 [download PDF]