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Оптимизация контроля артериального давления у пациентов с резистентной артериальной гипертензией и висцеральным ожирением
Оптимизация контроля артериального давления у пациентов с резистентной артериальной гипертензией и висцеральным ожирением
Денека И.Э., Родионов А.В., Фомин В.В. Оптимизация контроля артериального давления у пациентов с резистентной артериальной гипертензией и висцеральным ожирением. Consilium Medicum. 2022;24(10):671–680. DOI: 10.26442/20751753.2022.10.201856
© ООО «КОНСИЛИУМ МЕДИКУМ», 2022 г.
© ООО «КОНСИЛИУМ МЕДИКУМ», 2022 г.
________________________________________________
Материалы доступны только для специалистов сферы здравоохранения. Авторизуйтесь или зарегистрируйтесь.
Аннотация
Цель. Изучить особенности течения резистентной артериальной гипертензии в популяции пациентов с висцеральным ожирением, выявить предикторы неудовлетворительных ближайших и отдаленных результатов лечения, оптимизировать терапию и повысить приверженность терапии.
Материалы и методы. В исследование включали пациентов с истинной резистентной артериальной гипертензией и висцеральным ожирением; 30 участников вошли в проспективную группу индивидуализированного ведения и 60 – в ретроспективную группу, отражающую реальную клиническую практику. Исходно все пациенты принимали блокаторы рецепторов ангиотензина (БРА)/ингибиторы ангиотензинпревращающего фермента, блокаторы кальциевых каналов (БКК) и диуретик. После первичного обследования всем пациентам скорректировали терапию в соответствии с актуальными клиническими рекомендациями. Большинство пациентов в ретроспективной группе получили БРА валсартан и лозартан, БКК амлодипин, диуретики индапамид и торасемид, β-адреноблокаторы бисопролол и метопролол, α2-адреномиметик моксонидин, антагонист минералокортикоидных рецепторов спиронолактон. В проспективной группе препаратами выбора стали БРА телмисартан и азилсартан, БКК лерканидипин, диуретики индапамид и хлорталидон, β-адреноблокаторы небиволол и карведилол, α1-адреноблокатор доксазозин, спиронолактон. Повторное обследование выполнили через 2 мес. В дальнейшем в течение 8 мес с участниками из проспективной группы поддерживали регулярную обратную связь при помощи мессенджера. С пациентами из ретроспективной группы контакт не поддерживался. Затем со всеми участниками провели телефонное интервьюирование.
Результаты. Через 2 мес после коррекции терапии в ретроспективной группе целевых значений среднесуточного систолического и диастолического артериального давления достигли 35 и 36,7% пациентов, в проспективной – 66,7 и 60%. Через 10 мес по результатам интервьюирования в ретроспективной группе целевые значения САД и ДАД отмечены у 10 и 18,3% участников, в проспективной – у 93,3 и 96,7%. В ретроспективной группе ранее подобранную терапию поменяли 78,3% пациентов, в проспективной – 20%. В ретроспективной группе антропометрические показатели статистически не изменились, в проспективной группе масса тела и окружность талии достоверно уменьшились (p<0,05).
Заключение. Регулярная обратная связь и индивидуализированный подбор терапии с акцентом на современные метаболически нейтральные препараты с максимальной продолжительностью действия привели в проспективной группе к лучшему контролю АД, повышению приверженности терапии и достоверному снижению массы тела.
Ключевые слова: резистентная артериальная гипертензия, висцеральное ожирение, оптимальная медикаментозная терапия, приверженность, комплаентность
Materials and methods. A total number of 90 individuals with a history of refractory or resistant arterial hypertension (RAH) and visceral obesity (VO) were a subject of intensive study. The prospective analysis group consisted of 30 patients with an individualized management plan each, whereas the retrospective group of real clinical practice included 60 participants. At baseline, all patients were taking antihypertensives like ACE inhibitors or angiotensin II receptor blockers (ARBs)/angiotensin-converting enzyme inhibitors, calcium channel blockers (CCBs), and a diuretic. After the initial examination, therapy was individually optimized for each patient in accordance with current clinical guidelines. Most patients in the retrospective group received ARBs valsartan or losartan, CCBs amlodipine, the diuretics indapamide and torasemide, the β-blockers bisoprolol and metoprolol, the α2-agonist moxonidine, and the mineralocorticoid receptor antagonist spironolactone. Patients in the prospective group were prescribed ARBs telmisartan and azilsartan, the CCB lercanidipine, thiazide and thiazide-like diuretics indapamide and chlorthalidone, the β-blockers nebivolol and carvedilol, the α1-blocker doxazosin, and spironolactone. A re-examination was performed 2 months later. Subsequently, regular communication was maintained with participants of the prospective group during 8 months using a messenger. Communication with patients of the retrospective group was not maintained. All the patients were then asked to self-report their health status by conducting a telephone survey.
Results. After 2 months, according to the data of the follow-up, in the retrospective group the target values of mean daily SBP and DBP were observed in 35 and 36,7% of patients, though the statistics among the patients in the prospective group were 66,7 and 60%, respectively. After 10 months, according to the results of the interviews, the target values of SBP and DBP were observed in 10 and 18.3% of patients, though the statistics among the patients in the prospective group were 93.3 and 96.7%, respectively. In the retrospective group, 78.3% of patients changed the previously selected therapy, in the prospective group this figure was only 20%. In the retrospective group, anthropometric data did not change, while in the prospective group, weight and waist circumference significantly decreased (p<0.05).
Conclusion. Maintaining regular contact with patients and a well-rounded treatment strategy with individualized choice and dosage of medications with an emphasis on modern metabolically neutral drugs with a prolonged duration of action led to better BP control, increased adherence to therapy and indicated significant weight loss among the patients from the prospective group.
Keywords: resistant arterial hypertension, visceral obesity, optimal medical therapy, adherence, compliance
Материалы и методы. В исследование включали пациентов с истинной резистентной артериальной гипертензией и висцеральным ожирением; 30 участников вошли в проспективную группу индивидуализированного ведения и 60 – в ретроспективную группу, отражающую реальную клиническую практику. Исходно все пациенты принимали блокаторы рецепторов ангиотензина (БРА)/ингибиторы ангиотензинпревращающего фермента, блокаторы кальциевых каналов (БКК) и диуретик. После первичного обследования всем пациентам скорректировали терапию в соответствии с актуальными клиническими рекомендациями. Большинство пациентов в ретроспективной группе получили БРА валсартан и лозартан, БКК амлодипин, диуретики индапамид и торасемид, β-адреноблокаторы бисопролол и метопролол, α2-адреномиметик моксонидин, антагонист минералокортикоидных рецепторов спиронолактон. В проспективной группе препаратами выбора стали БРА телмисартан и азилсартан, БКК лерканидипин, диуретики индапамид и хлорталидон, β-адреноблокаторы небиволол и карведилол, α1-адреноблокатор доксазозин, спиронолактон. Повторное обследование выполнили через 2 мес. В дальнейшем в течение 8 мес с участниками из проспективной группы поддерживали регулярную обратную связь при помощи мессенджера. С пациентами из ретроспективной группы контакт не поддерживался. Затем со всеми участниками провели телефонное интервьюирование.
Результаты. Через 2 мес после коррекции терапии в ретроспективной группе целевых значений среднесуточного систолического и диастолического артериального давления достигли 35 и 36,7% пациентов, в проспективной – 66,7 и 60%. Через 10 мес по результатам интервьюирования в ретроспективной группе целевые значения САД и ДАД отмечены у 10 и 18,3% участников, в проспективной – у 93,3 и 96,7%. В ретроспективной группе ранее подобранную терапию поменяли 78,3% пациентов, в проспективной – 20%. В ретроспективной группе антропометрические показатели статистически не изменились, в проспективной группе масса тела и окружность талии достоверно уменьшились (p<0,05).
Заключение. Регулярная обратная связь и индивидуализированный подбор терапии с акцентом на современные метаболически нейтральные препараты с максимальной продолжительностью действия привели в проспективной группе к лучшему контролю АД, повышению приверженности терапии и достоверному снижению массы тела.
Ключевые слова: резистентная артериальная гипертензия, висцеральное ожирение, оптимальная медикаментозная терапия, приверженность, комплаентность
________________________________________________
Materials and methods. A total number of 90 individuals with a history of refractory or resistant arterial hypertension (RAH) and visceral obesity (VO) were a subject of intensive study. The prospective analysis group consisted of 30 patients with an individualized management plan each, whereas the retrospective group of real clinical practice included 60 participants. At baseline, all patients were taking antihypertensives like ACE inhibitors or angiotensin II receptor blockers (ARBs)/angiotensin-converting enzyme inhibitors, calcium channel blockers (CCBs), and a diuretic. After the initial examination, therapy was individually optimized for each patient in accordance with current clinical guidelines. Most patients in the retrospective group received ARBs valsartan or losartan, CCBs amlodipine, the diuretics indapamide and torasemide, the β-blockers bisoprolol and metoprolol, the α2-agonist moxonidine, and the mineralocorticoid receptor antagonist spironolactone. Patients in the prospective group were prescribed ARBs telmisartan and azilsartan, the CCB lercanidipine, thiazide and thiazide-like diuretics indapamide and chlorthalidone, the β-blockers nebivolol and carvedilol, the α1-blocker doxazosin, and spironolactone. A re-examination was performed 2 months later. Subsequently, regular communication was maintained with participants of the prospective group during 8 months using a messenger. Communication with patients of the retrospective group was not maintained. All the patients were then asked to self-report their health status by conducting a telephone survey.
Results. After 2 months, according to the data of the follow-up, in the retrospective group the target values of mean daily SBP and DBP were observed in 35 and 36,7% of patients, though the statistics among the patients in the prospective group were 66,7 and 60%, respectively. After 10 months, according to the results of the interviews, the target values of SBP and DBP were observed in 10 and 18.3% of patients, though the statistics among the patients in the prospective group were 93.3 and 96.7%, respectively. In the retrospective group, 78.3% of patients changed the previously selected therapy, in the prospective group this figure was only 20%. In the retrospective group, anthropometric data did not change, while in the prospective group, weight and waist circumference significantly decreased (p<0.05).
Conclusion. Maintaining regular contact with patients and a well-rounded treatment strategy with individualized choice and dosage of medications with an emphasis on modern metabolically neutral drugs with a prolonged duration of action led to better BP control, increased adherence to therapy and indicated significant weight loss among the patients from the prospective group.
Keywords: resistant arterial hypertension, visceral obesity, optimal medical therapy, adherence, compliance
Полный текст
Список литературы
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4. Chazova IE, Zhernakova YV. An international multicenter observational non-interventional prospective study of the efficacy of azilsartan medoxomil in overweight or obese patients with arterial hypertension (CONSTANT). Curr Med Res Opin. 2021;37(2):185-93.
5. Akagi H, Niwa M, Mizuno Y, et al. ALICE (All-Literature Investigation of Cardiovascular Evidence) Group. Telmisartan as a metabolic sartan: the first meta-analysis of randomized controlled trials in metabolic syndrome. J Am Soc Hypertens. 2013;7(3):229-35.
6. Barrios V, Escobar C, de la Figuera M, et al. High doses of lercanidipine are better tolerated than other dihydropyridines in hypertensive patients with metabolic syndrome: results from the TOLERANCE study. Int J Clin Pract. 2008;62(5):723-8.
7. Noble RE, Webb EL, Godfrey JC, et al. Indapamide in the stepped-care treatment of obese hypertensive patients. Curr Med Res Opin. 1983;8(Suppl 3):93-104.
8. Кобалава Ж.Д., Кулаков В.В., Горева Л.А., Виллевальде С.В. Сравнительные антигипертензивные эффекты хлорталидона и индапамида-ретард в комбинации с азилсартаном медоксомил у пациентов с артериальной гипертонией. Российский кардиологический журнал. 2019;(6):122‑30 [Kobalava ZD, Kulakov VV, Goreva LA, Villevalde SV. Comparative analysis of antihypertensive effects of chlorthalidone and indapamide-retard in combination with azilsartan medoxomil in patients with arterial hypertension. Russian Journal of Cardiology. 2019;(6):122-30 (in Russian)].
9. Torp-Pedersen C, Metra M, Charlesworth A, et al. COMET investigators. Effects of metoprolol and carvedilol on pre-existing and new onset diabetes in patients with chronic heart failure: data from the Carvedilol Or Metoprolol European Trial (COMET). Heart. 2007;93(8):968-73.
10. Williams B, MacDonald TM, Morant S, et al. British Hypertension Society's PATHWAY Studies Group. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386(10008):2059-68.
11. de Souza F, Muxfeldt E, Fiszman R, et al. Efficacy of spironolactone therapy in patients with true resistant hypertension. Hypertension. 2010;55(1):147-52.
12. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA. 2000;283(15):1967-75.
13. Cohn JN, Pfeffer MA, Rouleau J, et al. MOXCON Investigators. Adverse mortality effect of central sympathetic inhibition with sustained-release moxonidine in patients with heart failure (MOXCON). Eur J Heart Fail. 2003;5(5):659-67.
14. Calhoun DA, Jones D, Textor S, et al. American Heart Association Professional Education Committee. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation. 2008;117(25):e510-26.
15. Borghi C, Cicero AFG. Improving adherence with treatment-resistant hypertension. Expert Opin Pharmacother. 2021;22(11):1373-5.
16. Kiselev AR, Gridnev VI, Shvartz VA, et al. Active ambulatory care management supported by short message services and mobile phone technology in patients with arterial hypertension. J Am Soc Hypertens. 2012;6(5):346-55.
17. Juraschek SP, Miller ER, Weaver CM, et al. Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure. J Am Coll Cardiol. 2017;70(23):2841-8.
18. Bjelland I, Dahl AA, Haug TT, et al. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002;52(2):69-77.
19. Morisky DE, Ang A, Krousel-Wood M, et al. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10(5):348-54.
20. Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients (3rd ed.). London: CRC Press, 2013.
2. Williams B, Mancia G, Spiering W, et al. ESC Scientific Document Group. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-104.
3. Kobalava ZD, Konradi AO, Nedogoda SV, et al. Arterial hypertension in adults. Clinical guidelines 2020. Russian Journal of Cardiology. 2020;25(3):3786 (in Russian).
4. Chazova IE, Zhernakova YV. An international multicenter observational non-interventional prospective study of the efficacy of azilsartan medoxomil in overweight or obese patients with arterial hypertension (CONSTANT). Curr Med Res Opin. 2021;37(2):185-93.
5. Akagi H, Niwa M, Mizuno Y, et al. ALICE (All-Literature Investigation of Cardiovascular Evidence) Group. Telmisartan as a metabolic sartan: the first meta-analysis of randomized controlled trials in metabolic syndrome. J Am Soc Hypertens. 2013;7(3):229-35.
6. Barrios V, Escobar C, de la Figuera M, et al. High doses of lercanidipine are better tolerated than other dihydropyridines in hypertensive patients with metabolic syndrome: results from the TOLERANCE study. Int J Clin Pract. 2008;62(5):723-8.
7. Noble RE, Webb EL, Godfrey JC, et al. Indapamide in the stepped-care treatment of obese hypertensive patients. Curr Med Res Opin. 1983;8(Suppl 3):93-104.
8. Kobalava ZD, Kulakov VV, Goreva LA, Villevalde SV. Comparative analysis of antihypertensive effects of chlorthalidone and indapamide-retard in combination with azilsartan medoxomil in patients with arterial hypertension. Russian Journal of Cardiology. 2019;(6):122-30 (in Russian).
9. Torp-Pedersen C, Metra M, Charlesworth A, et al. COMET investigators. Effects of metoprolol and carvedilol on pre-existing and new onset diabetes in patients with chronic heart failure: data from the Carvedilol Or Metoprolol European Trial (COMET). Heart. 2007;93(8):968-73.
10. Williams B, MacDonald TM, Morant S, et al. British Hypertension Society's PATHWAY Studies Group. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386(10008):2059-68.
11. de Souza F, Muxfeldt E, Fiszman R, et al. Efficacy of spironolactone therapy in patients with true resistant hypertension. Hypertension. 2010;55(1):147-52.
12. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA. 2000;283(15):1967-75.
13. Cohn JN, Pfeffer MA, Rouleau J, et al. MOXCON Investigators. Adverse mortality effect of central sympathetic inhibition with sustained-release moxonidine in patients with heart failure (MOXCON). Eur J Heart Fail. 2003;5(5):659-67.
14. Calhoun DA, Jones D, Textor S, et al. American Heart Association Professional Education Committee. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation. 2008;117(25):e510-26.
15. Borghi C, Cicero AFG. Improving adherence with treatment-resistant hypertension. Expert Opin Pharmacother. 2021;22(11):1373-5.
16. Kiselev AR, Gridnev VI, Shvartz VA, et al. Active ambulatory care management supported by short message services and mobile phone technology in patients with arterial hypertension. J Am Soc Hypertens. 2012;6(5):346-55.
17. Juraschek SP, Miller ER, Weaver CM, et al. Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure. J Am Coll Cardiol. 2017;70(23):2841-8.
18. Bjelland I, Dahl AA, Haug TT, et al. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002;52(2):69-77.
19. Morisky DE, Ang A, Krousel-Wood M, et al. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10(5):348-54.
20. Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients (3rd ed.). London: CRC Press, 2013.
2. Williams B, Mancia G, Spiering W, et al. ESC Scientific Document Group. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-104.
3. Кобалава Ж.Д., Конради А.О., Недогода С.В., и др. Артериальная гипертензия у взрослых. Клинические рекомендации 2020. Российский кардиологический журнал. 2020;25(3):3786 [Kobalava ZD, Konradi AO, Nedogoda SV, et al. Arterial hypertension in adults. Clinical guidelines 2020. Russian Journal of Cardiology. 2020;25(3):3786 (in Russian)].
4. Chazova IE, Zhernakova YV. An international multicenter observational non-interventional prospective study of the efficacy of azilsartan medoxomil in overweight or obese patients with arterial hypertension (CONSTANT). Curr Med Res Opin. 2021;37(2):185-93.
5. Akagi H, Niwa M, Mizuno Y, et al. ALICE (All-Literature Investigation of Cardiovascular Evidence) Group. Telmisartan as a metabolic sartan: the first meta-analysis of randomized controlled trials in metabolic syndrome. J Am Soc Hypertens. 2013;7(3):229-35.
6. Barrios V, Escobar C, de la Figuera M, et al. High doses of lercanidipine are better tolerated than other dihydropyridines in hypertensive patients with metabolic syndrome: results from the TOLERANCE study. Int J Clin Pract. 2008;62(5):723-8.
7. Noble RE, Webb EL, Godfrey JC, et al. Indapamide in the stepped-care treatment of obese hypertensive patients. Curr Med Res Opin. 1983;8(Suppl 3):93-104.
8. Кобалава Ж.Д., Кулаков В.В., Горева Л.А., Виллевальде С.В. Сравнительные антигипертензивные эффекты хлорталидона и индапамида-ретард в комбинации с азилсартаном медоксомил у пациентов с артериальной гипертонией. Российский кардиологический журнал. 2019;(6):122‑30 [Kobalava ZD, Kulakov VV, Goreva LA, Villevalde SV. Comparative analysis of antihypertensive effects of chlorthalidone and indapamide-retard in combination with azilsartan medoxomil in patients with arterial hypertension. Russian Journal of Cardiology. 2019;(6):122-30 (in Russian)].
9. Torp-Pedersen C, Metra M, Charlesworth A, et al. COMET investigators. Effects of metoprolol and carvedilol on pre-existing and new onset diabetes in patients with chronic heart failure: data from the Carvedilol Or Metoprolol European Trial (COMET). Heart. 2007;93(8):968-73.
10. Williams B, MacDonald TM, Morant S, et al. British Hypertension Society's PATHWAY Studies Group. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386(10008):2059-68.
11. de Souza F, Muxfeldt E, Fiszman R, et al. Efficacy of spironolactone therapy in patients with true resistant hypertension. Hypertension. 2010;55(1):147-52.
12. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA. 2000;283(15):1967-75.
13. Cohn JN, Pfeffer MA, Rouleau J, et al. MOXCON Investigators. Adverse mortality effect of central sympathetic inhibition with sustained-release moxonidine in patients with heart failure (MOXCON). Eur J Heart Fail. 2003;5(5):659-67.
14. Calhoun DA, Jones D, Textor S, et al. American Heart Association Professional Education Committee. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation. 2008;117(25):e510-26.
15. Borghi C, Cicero AFG. Improving adherence with treatment-resistant hypertension. Expert Opin Pharmacother. 2021;22(11):1373-5.
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14. Calhoun DA, Jones D, Textor S, et al. American Heart Association Professional Education Committee. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation. 2008;117(25):e510-26.
15. Borghi C, Cicero AFG. Improving adherence with treatment-resistant hypertension. Expert Opin Pharmacother. 2021;22(11):1373-5.
16. Kiselev AR, Gridnev VI, Shvartz VA, et al. Active ambulatory care management supported by short message services and mobile phone technology in patients with arterial hypertension. J Am Soc Hypertens. 2012;6(5):346-55.
17. Juraschek SP, Miller ER, Weaver CM, et al. Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure. J Am Coll Cardiol. 2017;70(23):2841-8.
18. Bjelland I, Dahl AA, Haug TT, et al. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002;52(2):69-77.
19. Morisky DE, Ang A, Krousel-Wood M, et al. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10(5):348-54.
20. Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients (3rd ed.). London: CRC Press, 2013.
Авторы
И.Э. Денека*1, А.В. Родионов2, В.В. Фомин2
1 ООО «Клиники Чайка», Москва, Россия;
2 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*denekairina@gmail.com
1 Chaika Clinics, Moscow, Russia;
2 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*denekairina@gmail.com
1 ООО «Клиники Чайка», Москва, Россия;
2 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*denekairina@gmail.com
________________________________________________
1 Chaika Clinics, Moscow, Russia;
2 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*denekairina@gmail.com
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