There is probably no person who has never experienced high blood pressure throughout his life. Hypertension can be short-term - caused by severe stress or excessive physical exertion. But in many people, hypertension becomes chronic, and then during diagnosis, doctors must determine the degree of arterial hypertension (AH) and assess potential health risks.

What is arterial hypertension

Pressure in the arteries of the systemic circulation plays an important role in human life. If it is constantly elevated, this is arterial hypertension. Depending on the degree of increase in systolic and diastolic pressure, 4 stages of arterial hypertension are distinguished. In the initial stages, the disease is asymptomatic.

Causes

The first degree of arterial hypertension often develops due to improper lifestyle. Lack of sleep, nervous tension and bad habits provoke vasoconstriction. Blood begins to press on the arteries with greater force, which leads to hypertension. Factors that provoke the appearance of primary and secondary hypertension include:

• physical inactivity;
• obesity;
• hereditary predisposition;
• vitamin D deficiency;
• sodium sensitivity;
• hypokalemia;
• elevated cholesterol levels;
• the presence of chronic diseases of internal organs.

Classification

The disease is divided depending on the causes of its development and blood pressure levels. Based on the nature of the disease, primary and secondary hypertension are distinguished. With primary, or essential arterial hypertension, patients’ blood pressure simply rises, but there are no pathologies of the internal organs. There are several types of it: hyperadrenergic, hyporeninic, normoreninic, hyperreninic. The main problem in the treatment of primary hypertension is that the causes of its occurrence have not yet been studied.

The classification of secondary hypertension is as follows:

• neurogenic;
• hemodynamic;
• endocrine;
• medicinal;
• nephrogenic.

With the neurogenic type of the disease, patients experience problems in the peripheral and central nervous systems caused by brain tumors, circulatory failure or stroke. Hemodynamic symptomatic hypertension is accompanied by heart disease and aortic pathologies. The endocrine form of the disease can be caused by active work of the adrenal glands or thyroid gland.

Nephrogenic hypertension is considered the most dangerous, because often accompanied by polycystic disease, pyelonephritis and other kidney pathologies. The dosage form occurs against the background of uncontrolled use of medications that affect vascular density or the functioning of the endocrine system.

Degrees of hypertension - table

Currently, when examining patients with suspected hypertension, the Korotkoff method is used. This method of examining patients was officially approved by the World Health Organization (WHO) in 1935. Before diagnosing a patient with any degree of arterial hypertension, pressure measurements are taken on each arm 3 times. A difference of 10-15 mm indicates pathology of peripheral vessels. Degrees of hypertension in relation to blood pressure indicators:

Blood pressure (BP)	Systolic blood pressure	Diastolic blood pressure
Optimal
Normal
Upper limit of normal
AH 1st degree
AH 2 degrees
AH 3 degrees
4th degree hypertension
Isolated systolic hypertension

Risk stratification for arterial hypertension

All patients are divided into several groups depending on their health status and degree of hypertension. Stratification (risk assessment) is influenced not only by blood pressure, but also by the patient’s age and lifestyle. The main risk factors include dyslipidemia, a family history of early development of cardiovascular diseases, excess C-reactive protein, abdominal obesity, and smoking. In addition, take into account:

• impaired glucose tolerance;
• high levels of fibrinogen;
• physical inactivity;
• presence of diabetes mellitus;
• target organ damage;
• diseases of the endocrine system;
• the appearance of signs of thickening of the arteries;
• kidney and heart diseases;
• circulatory disorders.

In women, the chances of getting complications increase after 65 years of age, in men - earlier, at 55 years of age. The risk of complications will be low if the patient is exposed to no more than one or two adverse factors. Such patients almost always have grade 1 hypertension. When assessing the condition of elderly patients (over 65 years of age), doctors rarely indicate low risk in the medical history, because In this age category, the chance of developing vascular atherosclerosis is 80%. They are immediately placed in a high-risk group.

Hypertension 1 degree

The disease is often iatrogenic, i.e. occurs when taking medications containing artificial hormones. Arterial hypertension of the 1st degree can be primary or secondary. The essential form of the disease is accompanied only by increased blood pressure. In the secondary form, the patient’s medical history contains other pathologies that provoke the development of hypertension. The disease often occurs during pregnancy and is asymptomatic in 90% of patients.

Normalization of blood pressure is facilitated by reducing body weight and increasing physical activity. The patient does not need to start heavy and grueling training. Daily 30-minute walks in the fresh air will help you recover from stage 1 arterial hypertension. Hypertensive patients should adjust their diet by excluding too salty and fatty foods from the menu. Liquid intake should be limited for a while. Medicines for the first type of hypertension are not prescribed.

Risk 1

This group includes patients under 55 years of age who suffer from mild high blood pressure. There must be no other risk factors. If blood pressure is normal, non-drug therapy is recommended. It is also suitable for labile arterial hypertension, when the symptoms of the disease appear periodically. Primary prevention of complications includes normalization of body mass index, diet correction and elimination of muscular dystrophy.

Risk 2

Patients suffering from exposure to 2-3 unfavorable factors fall into this group. The first degree of arterial hypertension with risk 2 is characterized by the appearance of the first symptoms of high blood pressure. Patients complain of migraines, spots in the eyes and dizziness. The patient can only get rid of the disease with the help of drug therapy. Complications in patients at moderate risk occur in 15-20% of cases.

Risk 3

Many patients assume that type 1 hypertension is mild and goes away on its own. But without treatment, any person can develop complications. At risk 3, patients experience swelling, lethargy, angina, fatigue, because The kidneys begin to suffer from pathology. Hypertensive crises may occur, characterized by increased heart rate and hand tremors. Further complications develop with a probability of 20-30%.

Risk 4

In this group, cardiovascular complications occur in more than 30% of patients. This risk is diagnosed in a patient if potential aggravating factors are present. These include chronic renal failure, congenital lesions of the blood vessels of the brain and other organs. At risk 4, the disease progresses to the second or third degree within 6-7 months.

Hypertension 2 degrees

A mild form of the disease is accompanied by typical signs of high blood pressure: nausea, fatigue, headache. With grade 2 hypertension, the likelihood of left ventricular hypertrophy increases. The muscles begin to contract more strongly to resist the flow of blood, which leads to the growth of muscle tissue and disruption of the heart. Clinical manifestations of this form of hypertension:

• vascular insufficiency;
• narrowing of arterioles;
• sensation of pulsation in the temples;
• numbness of the limbs;
• pathology of the fundus.

Arterial hypertension of the 2nd degree can be diagnosed if only the diastolic or systolic blood pressure is exceeded. Monotherapy works well for this form of the disease. It is used when high blood pressure does not pose a risk to the patient’s life and does not affect his ability to work. If it is difficult for the patient to work during attacks, treatment with combination drugs is started.

Risk 2

Hypertension is mild. The patient complains of migraine and pain in the heart area. At risk 2, the patient is exposed to one or two unfavorable factors, so the percentage of complications in this group is less than 10. Sensitive people experience skin hyperemia. There are no target organ lesions. Treatment consists of taking one type of antihypertensive medication and adjusting your diet.

Risk 3

Arterial hypertension can be detected by the presence of albumin proteins in the urine. The patient not only swells his limbs, but also his face. A hypertensive patient complains of blurred vision. The walls of blood vessels become thicker. The risk of complications reaches 25%. Treatment consists of taking medications that normalize blood pressure and restore the functioning of organs damaged by the disease.

Risk 4

With an unfavorable course of the disease, symptoms of target organ damage appear. Patients suffer from sudden surges in pressure of 59 units or more. The transition of hypertension to the next stage without treatment will take 2-3 months. In case of persistent impairment of body functions, hypertensive patients with risk 4 are assigned disability groups 2 or 3. The health status continues to deteriorate in 40% of patients.

Hypertension 3 degrees

The systolic pressure at this stage of the disease is equal to or more than 180 mm Hg. Art., and diastolic – 110 mm Hg. and higher. Vascular tissues in the third degree of arterial hypertension are very damaged. Patients often suffer from hypertensive crises and angina. Blood pressure readings are always elevated. The disease is accompanied by the following symptoms:

• dizziness and constant migraines;
• the appearance of spots before the eyes;
• muscle weakness;
• damage to retinal vessels;
• deterioration in vision clarity;

Treatment of high blood pressure in stage 3 hypertension includes drug therapy, diet and exercise. Hypertensive patients must give up smoking and alcohol. Taking one drug will not help cope with high blood pressure in this form of the disease. Doctors prescribe diuretics, calcium channel blockers, and angiotensin-converting enzyme (ACE) inhibitors to patients. The disease is considered resistant if the use of 3-4 drugs failed to normalize the patient’s condition.

Risk 3

The group includes patients who may become disabled. Hypertension of grade 3 with risk of 3 is accompanied by large-scale damage to target organs. The kidneys, heart, brain, and retina suffer from high blood pressure. The left ventricle expands, which is accompanied by growth of the muscle layer. The myocardium begins to lose its elastic properties. The patient develops hemodynamic instability.

Risk 4

The group consists of patients with malignant arterial hypertension. Patients suffer from periodic transient attacks, which leads to the development of severe complications, including stroke. Mortality in this group of patients is high. With increased severity of arterial hypertension, patients are assigned disability group 1.

Hypertension 4 degrees

This stage of hypertension is considered very severe. In 80% of patients, death occurs within a couple of months after the disease transitions to this form. In case of a hypertensive crisis, it is important to quickly provide first aid to the patient. It is necessary to lay it on a flat surface, slightly raise its head. The patient is given antihypertensive tablets that sharply lower blood pressure.

Stage 4 arterial hypertension is characterized by 2 forms of course: primary and secondary. The main difference between this type of disease and others are the complications that accompany attacks. When pressure increases, patients experience disturbances in cerebral, coronary, and renal circulation. The cardiovascular system suffers from constant overload, which leads to disability of the patient.

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Note:
National
Clinical guidelines VNOK, 2010.

1. Hypertension, stage II. Degree
arterial hypertension 3. Dyslipidemia.
Left ventricular hypertrophy. Obesity, II degree. Breakdown of tolerance
to glucose. Risk 4 (very high).

2. Hypertension, stage III. Degree of arterial hypertension
2. IHD. Angina pectoris, IIFC. Risk 4 (very high).
KhSNIIА st., IIIFK.

3. Hypertension, III degree. Achieved AGI degree/
Obliterating atherosclerosis of the lower
limbs. Intermittent claudication.
Risk 4 (very high).

4. Pheochromocytoma of the right adrenal gland.
AG IIIst. Hypertrophy
left ventricle. Risk 4 (very high).

Restrictions.

It should be recognized,
that all existing models today
cardiovascular risk assessments have
restrictions. Meaning of defeat
target organs to calculate total
risk depends on how carefully
this lesion was assessed using
available examination methods. It is forbidden
not to mention the conceptual
restrictions.

At
the formulation of the diagnosis of hypertension should indicate
stage, extent of disease and extent
risk. In persons with newly diagnosed hypertension and
not receiving antihypertensive drugs
therapy degree of arterial hypertension
it is inappropriate to indicate. Besides,
It is recommended to detail the available
damage to target organs, factors
risk and associated clinical
states.

Algorithm for emergency care during a hypertensive crisis

Hypertensive crises (HC) are divided into
into two large groups - complicated
(life-threatening) uncomplicated
(non-life-threatening) GK.

Uncomplicated
hypertensive crisis,
despite the pronounced clinical
symptoms, not accompanied by acute
clinically significant impairment of function
target organs.

Complicated
hypertensive crisis
accompanied by life-threatening
complications, emergence or worsening
target organ damage and requires
decrease in blood pressure, starting from the first minutes, in
within a few minutes or hours
with the help of parenterally administered drugs.

HA is considered complicated in the following
cases:

hypertensive
encephalopathy;

cerebral stroke
(MI);

acute coronary
syndrome (ACS);

acute left ventricular
failure;

delaminating
aortic aneurysm;

hypertensive
crisis with pheochromocytoma;

preeclampsia or
eclampsia in pregnancy;

heavy
Hypertension associated with subarachnoid
hemorrhage or head injury
brain;

AG
in postoperative patients and with
risk of bleeding;

hypertensive
crisis due to the use of amphetamines, cocaine
and etc.

Hypertension, stage III. Degree of arterial hypertensionIII. Left hypertrophy
ventricle Uncomplicated hypertensive
crisis from 03/15/2010. Risk 4 (very high). KhSNIIА st.,

Hypertensive
crisis in young and middle-aged people
in the early stages of HD development (I-II
stage) with predominance in the clinic
neuro-vegetative symptoms. In that
in case of crisis relief they use
the following drugs:

Propranolol
(anaprilin, obzidan, inderal) is administered
3-5 ml of 0.1% solution (3-5 mg) in 10-15 ml
isotonic sodium chloride solution
intravenously in a slow stream.

Seduxen 2 ml (10
mg) per 10 ml of isotonic solution
intravenous stream;

Dibazol 6-8 ml
0.5-1.0% solution is administered intravenously;

Clonidine
prescribed in a dose of 0.5-2 ml of 0.1% solution
intravenously in 10-20 ml physiological
solution, injected slowly over
3-5 min.

1. Corinfar 10-20 mg. Sublingually (do not use in patients with myocardial infarction, unstable angina pectoris, heart failure) or hood 12.5-25-50 mg. Under the tongue or clonidine0,000075-0,00015 under the tongue (do not use in patients with damage to cerebral vessels)

1. nitroglycerine0.5 mg. under the tongue again after 3-5 minutes 2. pentamine 5% -0.3-1 ml. into the vein slowly 3 . lasix up to 100 mg. into a vein 4. morphine 1% -1 ml. or promedol 2% -1 ml. into a vein. 5. droperidol0,25%-1-2 ml. into a vein orrelanium 10 mg. (2 ml.) into a vein. 6. moisturized oxygen through alcohol.

1. pentamine 5% -0.3-1 ml. into the vein slowly. 2. relanium 10 mg. (2 ml.) into a vein or droperidol 0.25% -1-2 ml. into a vein. 3. sodium hydroxybutyrate 20% -10 ml. into a vein 4. lasix 20-40 mg. into a vein 5 . aminophylline 2.4% -10 ml. into a vein.

At no effect: 2. pentamine 5% - 0.3-1 ml. into the vein slowly 3. to enhance the hypotensive effect and/or normalization of emotional backgrounddroperidol0.25% -1-2 ml into a vein orrelanium 10 mg. (2 ml.) into a vein.

At no effect: 7. perlinganite (isoket) 0.1% -10 ml. V vein drip orsodiumnitroprusside 1,5 8. ECG recording

At no effect: 6. sodium nitroprusside 1,5 mcg/kg/min into a vein drip. 7. ECG recording

Hypertensive
crisis proceeding according to the vegetative type
paroxysm
and accompanied by a feeling of fear,
anxiety, worry. These patients
the following medications are indicated
facilities:

droperidol 2 ml
0.25% solution intravenously 10 ml isotonic
sodium chloride solution;

pyrroxan 1-2 ml
1% solution IM or subcutaneously;

aminazine
1-2 ml of 2.5% solution intramuscularly or
intravenously in 10 ml physiological
solution.

Hypertensive
crises in older people.
Proceed as cerebral ischemic
crises. With cerebral ischemic
crisis with vasospasm of the cerebral arteries
and the development of local cerebral ischemia are indicated
antispasmodics and diuretics:

aminophylline
5-10 ml 2.4% solution in 10-20 ml physiological
solution;

no-spa 2-4 ml 2-%
intravenous solution;

lasix 40-60 mg
intravenous stream;

clonidine
1-2 ml of 0.1% solution intravenously per 20 ml
physiological solution;

hyperstat
(diazoxide) 20 ml intravenously. Decline
BP in the first 5 minutes and remains
few hours.

Cerebral
angiodystonic crisis
with increased intracranial pressure.
In this situation, antispasmodics
contraindicated. Less desirable
also, intramuscular injection of sulfuric acid
magnesia, because dehydration effect
weak, comes late (after 40 minutes),
infiltrates often occur.

Analgin
50% solution 2 ml intravenously

Caffeine
10% solution 2 ml subcutaneously or cordiamine
1-2 ml intravenously slowly

Clonidine
2-1 ml 0.1% solution intravenously slowly

Lasix
20-40 mg intravenous bolus

Nitroprusside
sodium (nanipruss) 50 mg intravenously
dropwise in 250 ml of 5% glucose solution.

Pentamin
5% solution 0.5-1 ml with 1-2 ml droperidol
intravenous drip in 50 ml of physiological
solution

Lasix 80-120 mg
intravenous stream slowly or
drip.

Fentanyl
1 ml and 2-4 ml of 0.25% solution of droperidol in 20
ml 5% glucose solution intravenously
jetly

Clonidine
1-2 ml of 0.1% solution intravenously per 20 ml
physiological solution.

Myocardial ischemia.

Low risk
(1)-less than 15%

Medium risk (2) –
15-20%

High risk (3) –
20-30%

Very tall
risk – 30% and higher.

For diagnostics
myocardial ischemia in hypertensive patients with LVH in
there are special procedures in reserve.
This diagnosis is especially difficult because
How does hypertension reduce specificity?
stress echocardiography and perfusion
scintigraphy. If the ECG results are
physical activity are positive or
cannot be interpreted
(ambiguous), then for reliable diagnosis
myocardial ischemia requires a technique,
allowing you to visualize the appearance
ischemia, for example, stress MRI of the heart,
perfusion scintigraphy or
stress echocardiography.

Definition of CHF

Continuous
the nature of the relationship between blood pressure and cardiovascular
and renal events makes it difficult to choose
borderline level of blood pressure, which separated
normal blood pressure versus high blood pressure.
An additional difficulty is
that in the general population the distribution
SBP and DBP values ​​are unimodal
character.

Table 1

#187; Arterial hypertension #187; Risk stratification for arterial hypertension

Hypertension is a disease in which there is an increase in blood pressure; the reasons for such an increase, as well as changes, may be different.

Risk stratification for arterial hypertension is an assessment system for the likelihood of complications of the disease on the general condition of the heart and vascular system.

The general assessment system is based on a number of special indicators that affect the quality of life and its duration for the patient.

Stratification of all risks for hypertension is based on an assessment of the following factors:

• degree of disease (assessed during examination);
• existing risk factors;
• diagnosing lesions and pathologies of target organs;
• clinic (this is determined individually for each patient).

All significant risks are listed in a special Risk Assessment List, which also contains recommendations for treatment and prevention of complications.

Stratification determines which risk factors can cause the development of cardiovascular diseases, the emergence of a new disorder, or the death of a patient from certain cardiac causes over the next ten years. Risk assessment is performed only after completing a general examination of the patient. All risks are divided into the following groups:

• up to 15% #8212; low level;
• from 15% to 20% #8212; the risk level is average;
• 20-30% #8212; level is high;
• From 30% #8212; the risk is very high.

The prognosis can be influenced by a variety of data, and they will be different for each patient. Factors contributing to the development of arterial hypertension and influencing the prognosis may be the following:

• obesity, increased body weight;
• bad habits (most often smoking, abuse of caffeine-containing products, alcohol), sedentary lifestyle, poor nutrition;
• changes in cholesterol levels;
• tolerance is broken (to carbohydrates);
• microalbuminuria (only for diabetes);
• fibrinogen value is increased;
• there is a high risk for ethnic, socio-economic groups;
• The region is characterized by an increased incidence of hypertension, diseases, and pathologies of the heart and blood vessels.

All risks that affect the prognosis of hypertension, according to WHO recommendations from 1999, can be divided into the following groups:

• Blood pressure rises to grade 1-3;
• age: women – from 65 years, men – from 55 years;
• bad habits (drinking alcohol, smoking);
• diabetes;
• a history of pathologies of the heart and blood vessels;
• serum cholesterol increases from 6.5 mmol per liter.

When assessing risks, attention must be paid to damage and disruption of target organs. These are diseases such as narrowing of the retinal arteries, general signs of the appearance of atherosclerotic plaques, a greatly increased plasma creatinine value, proteinuria, and hypertrophy of the left ventricular region.

Attention should be paid to the presence of clinical complications, including cerebrovascular (this is a transient attack, as well as hemorrhagic/ischemic stroke), various heart diseases (including failure, angina, heart attacks), kidney diseases (including failure, nephropathy), vascular pathologies (peripheral arteries, a disorder such as aneurysm dissection). Among the general risk factors, it is necessary to note the developed form of retinopathy in the form of papilloedema, exudates, and hemorrhage.

All these factors are determined by the observing specialist, who conducts a general risk assessment and makes a prognosis for the course of the disease for the next ten years.

Hypertension is a polyetiological disease, in other words, a combination of many risk factors leads to the development of the disease. therefore, the likelihood of headache occurrence is determined by the combination of these factors, the intensity of their action, and so on.

But as such, the occurrence of hypertension, especially if we talk about asymptomatic forms. does not have much practical significance, since a person can live for a long time without experiencing any difficulties and without even knowing that he is suffering from this disease.

The danger of the pathology and, accordingly, the medical significance of the disease lies in the development of cardiovascular complications.

Previously, it was believed that the likelihood of cardiovascular complications in hypertension was determined solely by blood pressure levels. And the higher the pressure, the greater the risk of complications.

Today, it has been established that the risk of developing complications is determined not only by blood pressure figures, but also by many other factors, in particular, it depends on the involvement of other organs and systems in the pathological process, as well as the presence of associated clinical conditions.

In this regard, all patients suffering from essential hypertension are usually divided into 4 groups, each of which has its own level of risk for developing cardiovascular complications.

1. Low risk. Men and women under 55 years of age who have stage 1 hypertension and no other cardiovascular diseases have a low risk of developing cardiovascular complications, which does not exceed 15%.

2. Average level.

This group includes patients who have risk factors for developing complications, in particular, high blood pressure, high blood cholesterol, impaired glucose tolerance, age over 55 years for men and 65 years for women, and a family history of hypertension. In this case, there is no damage to target organs or associated diseases. The risk of developing cardiovascular complications is 15-20%.

4. Very high risk group. This risk group includes patients who have associated diseases, in particular, coronary heart disease, have had a myocardial infarction, have a history of acute cerebrovascular accident, suffer from heart or kidney failure, as well as people who have a combination of hypertension and diabetes mellitus.

Note:* – presence of criteria 1 and 2
mandatory in all cases. (National
clinical guidelines VNOK, 2010).

1. Characteristic symptoms of HF or complaints
sick.

2. Physical examination findings
(inspection, palpation, auscultation) or
Clinical signs.

3. Objective (instrumental) data
examination methods (Table 2).

Significance of symptoms

Table 2 Criteria, used in determining diagnosis CHF
I. Symptoms (complaints)	II. Clinical signs	III. Objective signs of dysfunction hearts
Dyspnea (negligible to suffocating) Fast fatigue Heartbeat Orthopnea	Stagnation in the lungs (wheezing, x-ray of organs chest Peripheral swelling Tachycardia ((amp)gt;90–100 beats/min) Swollen jugular veins Hepatomegaly Rhythm canter (S 3) Cardiomegaly	ECG, chest x-ray Systolic dysfunction (↓ contractility) Diastolic dysfunction (Doppler echocardiography, LVDP) Hyperactivity MNUP
LVDP – filling pressure of the left ventricle MNUP – brain natriuretic peptide S3 – appearance 3rd tone

VNOK recommendations, 2010.

Diagnostic criteria for the chronic phase of CML.

Hypertensive
stage II disease. Degree – 3. Dyslipidemia.
Left ventricular hypertrophy. Risk 3
(high).

Hypertensive
Stage III disease. IHD. Angina pectoris
voltage II functional class.
Risk 4 (very high).

Hypertensive
stage II disease. Atherosclerosis of the aorta,
carotid arteries, Risk 3 (high).

— Combined or isolated increase
size of the spleen and/or liver.

— Shift in the leukocyte formula to the left
with the total number of myeloblasts and
promyelocytes more than 4%.

— Total number of blasts and promyelocytes
in the bone marrow more than 8%.

— In the sternal punctate: bone marrow
rich in cellular elements, many
myelo- and megakaryocytes. red sprout
narrowed, white expanded. Ratio
leuko/erythro reaches 10:1, 20:1 or more in
as a result of an increase in granulocytes.
The number of basophils is usually increased
and eosinophils.

— spleen dimensions ≥ 5 cm from under the edge
costal arch;

— percentage of blast cells in the blood ≥ 3%
and/or bone marrow ≥ 5%;

— hemoglobin level ≤ 100 g/l;

— percentage of eosinophils in the blood ≥ 4%.

Treatment-resistant increase
leukocyte count;

Refractory anemia or thrombocytopenia
(amp)lt; 100×109/l, not related to therapy;

Slow but steady increase
spleen during therapy (more than
than 10cm);

Detection of additional chromosomal
anomalies (trisomy 8 pairs, isochromosome
17, additional Ph chromosome);

The number of basophils in the blood ≥ 20%;

Presence in peripheral blood, bone
brain blast cells up to 10-29%;

Sum of blasts and promyelocytes ≥ 30% in
peripheral blood and/or bone
brain.

The diagnosis of blast crisis is established
if present in peripheral blood or
in the bone marrow there are more blast cells
30% or when extramedullary
foci of hematopoiesis (except the liver and
spleen).

Classification of chronic lymphocytic leukemia
(CLL): initial stage, advanced
stage, terminal stage.

Forms of the disease: rapidly progressive,
"frozen"

Classification of stages according to K. Rai.

0 — lymphocytosis: more than 15 X
109/l in blood, more than 40% in bone
brain. (Life expectancy as in
populations);

I - lymphocytosis increased lymphatic
nodes (life expectancy 9 years);

II - lymphocytosis, liver enlargement and/or
spleen regardless of enlargement
lymph nodes (l/u) (duration
life 6 years);

III - lymphocytosis anemia (hemoglobin
(amp)lt;110 g/l) regardless of the increase in l/u and
organs (life expectancy 1.5
of the year).

IV - lymphocytosis thrombocytopenia less
100 X 109/l,
regardless of the presence of anemia, increased
l / u and organs. (Median survival rate 1.5
of the year).

Classification of stages according to J.
Binet.

Stage A – Hb content more than 100 g/l, platelets more than 100 x 109/l,
enlargement of lymph nodes by 1-2
areas (life expectancy as
in the population).

Stage B – Hb more than 100 g/l,
platelets more than 100x109/l, increase
lymph nodes in 3 or more areas
(median survival 7 years).

Stage C - Hb less than 100 g/l,
platelets less than 100x109/l at any
number of zones with increased
lymph nodes and regardless of
organ enlargement (median survival
2 years).

Criteria for diagnosing CLL.

Absolute lymphocytosis in the blood more than 5
x 109/l. Sternal puncture - no
less than 30% of lymphocytes in bone punctate
brain (diagnosis verification method).

Immunological confirmation of presence
clonal B-cell character
lymphocytes.

Enlarged spleen and liver -
optional sign.

Auxiliary diagnostic sign
lymphatic tumor proliferation
— Botkin-Gumprecht cells in a blood smear
(leukolysis cells are
artifact: they are not in liquid blood, they
formed during the cooking process
smear)

Immunophenotyping, tumor
cells in CLL: CD– 5.19,
23.

Trephine biopsy (diffuse lymphatic
hyperplasia) and flowcytometry (determination
protein ZAP-70) allow
determine B cell infiltration and
carry out differential diagnosis
with lymphomas.

1. Chronic myeloid leukemia, phase
acceleration.

2. Chronic lymphocytic leukemia, typical
clinical option. High risk: III degree. by K.Rai,
stage C by J.Binet.

Intermittent

Symptoms less than once a week. Exacerbations short-term. Night symptoms no more than 2 times a month. FEV 1 Variability PEF or FEV 1 (amp)lt;20%.

Lightweight persistent

Symptoms more than once a week, but less than once a week day. Exacerbations Night symptoms more often than 2 times a month. FEV or PSV (amp)gt; 80% of the proper values. Variability PEF or FEV 1 (amp)lt;30%.

Persistent moderate severity

Symptoms daily. Exacerbations may interfere with activity and sleep. Night symptoms (amp)gt;1 time per week. Daily taking inhaled β2-agonists short action. FEV 1 or PSV 60-80% of the proper values. Variability PEF or FEV 1 (amp)gt;30%.

Heavy persistent

Symptoms daily. Frequent exacerbations. Frequent nocturnal asthma symptoms. Limitation physical activity. FEV 1 or PSV (amp)lt;60% of proper values Variability PEF or FEV 1 (amp)gt;30%.

Note: PEF – peak expiratory flow, FEV1 – forced expiratory volume in the first
second (GINA, 2007).

Bronchial asthma, mixed
(allergic, infectious-dependent)
form, moderate severity, stage IV, exacerbation, DNIIst.

- presence of symptoms of the disease,
leading to pulmonary

hypertension;

- anamnestic indications of chronic
bronchopulmonary

pathology;

- diffuse warm cyanosis;

- shortness of breath without orthopnea;

- hypertrophy of the right ventricle and right
atria on ECG: may appear
signs of overload of the right departments
heart (deviation of the axis of the QRS complex more than 90 degrees, increase in size
P wave in II, III standard leads more than 2 mm, P – “pulmonale” in II, III and aVF,
decrease in T wave amplitude in standard
and left chest leads, signs
LVMH.

With constant PH, the most reliable
signs of HBF are the following:
high or predominant RвV1,V3;
offset ST below isoline
inV1,V2;
appearance of Q in V1, V2 as a sign
overload of the right ventricle or its
dilation; shift of the transition zone to the left
kV4,V6;
widening of QRS in the right
chest leads, signs of complete
or incomplete blockade of the right bundle branch
Gisa.

— absence of atrial fibrillation;

- no signs of left overload
atria;

- X-ray confirmation
bronchopulmonary pathology, bulging
arches of the pulmonary artery, enlargement of the right
parts of the heart;

1. GMF (thickness of its anterior wall
exceeds 0.5 cm),

2. Dilation of the right heart
parts of the heart (RV EDR more than 2.5 cm),

3. Paradoxical movement of the interventricular
septum in diastole towards the left
departments,

4. Increased tricuspid regurgitation,

5. Increased pressure in the pulmonary artery.

Doppler echocardiography allows you to accurately measure
pulmonary artery pressure (normal)
pressure in the pulmonary artery up to 20
mmHg.)

COPD: severe, stage III, exacerbation. Emphysema.
CLS, stage of decompensation. DNIIst. CHSNIIА (IIIFC according to NYHA).

	Stages of CHF	Functional CHF classes
	Initial stage Hemodynamics are not impaired. Hidden heart failure. Asymptomatic LV dysfunction.		Limitation no physical activity: habitual physical activity is not accompanied by rapid fatigue, the appearance of shortness of breath or palpitations. The patient tolerates increased load, but it may be accompanied by shortness of breath and/or slow recovery strength
II A Art.	Clinically pronounced stage diseases (damages) of the heart. Hemodynamic impairment in one of the circles of blood circulation, expressed moderate. Adaptive remodeling heart and blood vessels.		Minor restriction of physical activity: at rest there are no symptoms, habitual physical activity accompanied by fatigue, shortness of breath or heartbeat.
	Heavy stage diseases (damages) of the heart. Marked changes in hemodynamics in both circulation circles. Maladaptive remodeling heart and blood vessels.		Noticeable restriction of physical activity: at rest there are no symptoms, physical lower intensity activity compared to usual loads accompanied by the appearance of symptoms.
	Ultimate stage heart damage. Pronounced changes hemodynamics and severe (irreversible) structural changes in target organs (heart, lungs, cerebral vessels brain, kidneys). Final stage organ remodeling.		Impossibility perform any physical load without discomfort; symptoms of heart failure present at rest and intensified with minimal physical activity.

Note. National clinical
VNOK recommendations, 2010.

Stages of CHF and functional classes of CHF,
may be different.

(example: CHF IIA stage, IIFC; CHFIII stage, IVFC.)

IHD: stable angina pectoris,
IIIFC. KhSNIIA,IIIFK.

ionizing
radiation, high frequency currents, vibration,
hot air, artificial lighting;
medicinal (non-steroidal)
anti-inflammatory drugs,
anticonvulsants, etc.) or
toxic agents (benzene and its
driven), as well as associated
with viruses (hepatitis, parvoviruses,
immune deficiency virus, virus
Epstein-Barr, cytomegalovirus) or
clonal diseases of hematopoiesis
(leukemia, malignant lymphoproliferation,
paroxysmal nocturnal hemoglobinuria),
as well as secondary aplasias that have developed
against the background of solid tumors, autoimmune
processes (systemic lupus erythematosus,
eosinophilic fasciitis, etc.).

- trilinear cytopenia: anemia,
granulocytopenia, thrombocytopenia;

- decreased bone marrow cellularity
and the absence of megakaryocytes according to
bone marrow punctate;

—
bone marrow aplasia in biopsy
ilium (predominance
fatty bone marrow).

Diagnosis
AA is installed
only after histological examination
bone marrow (trephine biopsy).

(Mikhailova
E.A., Ustinova E.N., Klyasova G.A., 2008).

Non-severe AA: granulocytopenia
(amp)gt;0.5x109.

Heavy
AA:cells
neutrophil series (amp)lt;0.5x109/l;

platelets
(amp)lt;20x109/l;

reticulocytes (amp)lt;1.0%.

Very
severe AA: granulocytopenia:
less than 0.2x109/l;

thrombocytopenia
less than 20x109/l.

Criteria for complete remission:

hemoglobin (amp)gt;100 g/l;

granulocytes (amp)gt;1.5x10 9 /l;

platelets (amp)gt;100.0x10 9 /l;

no need for replacement
therapy with blood components.

1) hemoglobin (amp)gt;80 g/l;

2) granulocytes (amp)gt;1.0x109/l;

3) platelets (amp)gt;20x109/l;

4) disappearance or significant
reducing dependence on transfusions
blood components.

Idiopathic aplastic anemia,
severe form.

(after Truelove and Witts, 1955)

Symptoms	Easy	Medium-heavy	Heavy
Frequency stools per day	less or equal to 4		more 6
Impurity blood in stool	small	moderate	significant
Fever	absent	low-grade fever	febrile
Tachycardia	absent	≤90V min	(amp)gt;90v min
Weight loss	absent	minor	expressed
Hemoglobin	(amp)gt;110g/l	90-100 g/l	(amp)lt;90 g/l
	≤30 mm/h	30-35 mm/h	(amp)gt;35 mm/h
Leukocytosis	absent	moderate	leukocytosis with formula shift
Weight loss	absent	minor	expressed
Symptoms malabsorption	none	minor	expressed

Nonspecific ulcerative colitis,
recurrent form, total variant,
severe course.

Classification of asthma severity according to clinical signs before treatment.

spicy
pericarditis (less
6 weeks):
fibrinous or dry and exudative;

chronic
pericarditis (more
3 months):
exudative and constrictive.

Heavy
form of VP is a special form of the disease
of various etiologies, manifested
severe respiratory failure
and/or signs of severe sepsis or
septic shock, characterized
poor prognosis and requiring
intensive care (Table 1).

Table 1

Clinical	Laboratory
1. Acute respiratory failure: — respiration rate (amp)gt; 30 per minute, 2. Hypotension — systolic blood pressure (amp)lt; 90 mm. Hg — diastolic blood pressure (amp)lt; 60 mm. Hg 3. Bi- or multilobar lesion 4. Impaired consciousness 5. Extrapulmonary infection (meningitis, pericarditis, etc.)	1. Leukopenia ((amp)lt; 4x10 9 /l) 2. Hypoxemia — SaO2 (amp)lt; 90% — PaO2 (amp)lt; 60 mmHg 3. Hemoglobin (amp)lt; 100g/l 4. Hematocrit (amp)lt; thirty% 5. Acute renal failure (anuria, blood creatinine (amp)gt; 176 µmol/l, BUN ≥ 7.0 mg/dL)

Complications
VP.

a) pleural effusion;

b) pleural empyema;

c) destruction/abscess formation
lung tissue;

d) acute respiratory
distress syndrome;

e) acute respiratory
failure;

f) septic shock;

g) secondary
bacteremia, sepsis, hematogenous focus
dropouts;

h) pericarditis,
myocarditis;

i) jade, etc.

Community-acquired polysegmental pneumonia
with localization in the lower lobe of the right
lung and lower lobe of the left lung,
severe form. Right-sided exudative
pleurisy. DN II.

Sick,
headache sufferers complain of headaches
pain, tinnitus, dizziness, mesh
- a veil" before the eyes when elevated
Blood pressure, often pain in the heart area.

Pain in the area
hearts:

Angina pectoris
all its varieties.

Pain manifested
during increases in blood pressure (they may have
both anginal and non-anginal
nature).

"Postdiuretic"
pain usually occurs after 12-24 hours.
after heavy diuresis, more often in women.
Aching or burning, lasting from
one to 2-3 days, these pains are felt
against a background of muscle weakness.

Another option
"pharmacological" pain is associated with
long-term use
sympatholytic agents.

Cardiac disorders
rhythm, especially tachyarrhythmia, often
accompanied by pain.

Neurotic pain
character /cardialgia/; not always
“privilege” of persons with borderline
arterial hypertension. These are long lasting
aching or pinching pain with spreading
under the left shoulder blade, in the left hand with
numbness of fingers.

Violations
heart rate
rare in patients with hypertension. Even with malignant
arterial hypertension extrasystole
and atrial fibrillation – not so common
finds. Since many HD patients
have been taking diuretics for years and months,
some of them cause extrasystole
and atrial fibrillation occurs
K ion deficiency
and metabolic alkalosis.

Objectively:
filling of the pulse on the radial arteries
identical and quite satisfactory.
In rare cases, pulse is detected
differens.
This is usually a consequence of incomplete occlusion
a large artery at its origin
from the aortic arch. For severe deficiency
myocardium in hypertension is characterized by alternating
pulse.

Important in
diagnostic data can be
obtained during examination of the aorta and
arterial vessels of the neck. Normally
people of average physical development
diameter of the aorta in x-ray
image is 2.4 cm, in persons with
fixed hypertension
increases to 3.4-4.2 cm.

Heart enlargement
with headache occurs in a certain
sequences. First into the process
the “outflow tract” of the left is involved
ventricle Concentric develops
hypertrophy, typical for long-term
isometric loads. With hypertrophy
and dilatation of the “inflow pathways” left
the ventricle enlarges posteriorly, narrowing
retrocardial space.

Auscultation
heart and blood vessels. Decreases
volume of 1 tone at the apex of the heart.
Frequent finding – 1U /atrial/ tone –
50% of patients, in II-III
GB stage. Ш /ventricular tone/ occurs
in approximately 1/3 of patients. Systolic
ejection noise in II
intercostal space on the right and at the apex of the heart.
Accent II
sounds on the aorta. Sympathetic musical
shade II
tones are evidence of duration and
severity of hypertension.

Routine tests

Hemoglobin and/or hematocrit

General cholesterol, lipoprotein cholesterol low density, cholesterol high density lipoproteins in serum.

Triglycerides fasting serum

Urinary whey acid

Creatinine serum (with GFR calculation)

Analysis urine with sediment microscopy, protein in urine test strip, analysis for microalbuminuria

Additional examination methods, taking into account the anamnesis, physical examination data and routine laboratory results analyzes

Glycated hemoglobin, if plasma glucose fasting (amp)gt;5.6 mmol/l (102 mg/dl) or if was previously diagnosed with diabetes.

Quantitative proteinuria assessment (if positive protein test using a test strip); potassium and sodium in urine and their ratio.

Homemade and daily ambulatory monitoring HELL

Holterovskoe ECG monitoring (in case of artymia)

Ultrasonic carotid artery examination

Ultrasonic study of peripheral arteries/abdominal cavity

Measurement pulse wave

Ankle-brachial index.

Advanced examination (usually carried out relevant specialists)

In-depth looking for signs of brain damage brain, heart, kidneys, blood vessels, required for resistant and complicated hypertension

Search causes of secondary hypertension, if so indicate data from anamnesis, physical examinations or routine and additional research methods.

There are 5 main
types of ECG for hypertension.

K I
type "hypertensive"
curve" we refer to ECGs with high amplitude,
symmetrical T waves in the left pectorals
leads

II
ECG type is possible
observe in patients with established
isometric hyperfunction of the left
ventricle Increased amplitude on the ECG
in the left chest leads, flattened,
two-phase 
or shallow, unequal tooth
T in lead AVL,
syndrome Tv1(amp)gt;Tv6,
sometimes deformation and widening of the P wave.

III
ECG type
occurs in patients with an increase in total
muscle mass of the left ventricle, although
his hypertrophy still has
concentric character. . On ECG
increase in the amplitude of the QRS complex
with deviation of its total vector
posteriorly and to the left, flattening or biphasic

T waves in lead I,
AVL,
V5-6,
sometimes combined with slight displacement
ST segment
downwards

IV
ECG type
typical for patients with advanced
clinic and more severe headache.
In addition to high-amplitude complexes
QRS
one can observe their increase
lasting more than 0.10 seconds, and
extension of internal deviation time
in leads V5-6
more than 0.05s. The transition zone shifts to
right chest abduction.

V
ECG type
reflects the presence of cardiosclerosis, etc.
complications of headache. Reducing amplitude
QRS complex, traces of transferred
heart attacks, intraventricular blockades.

If hypertensive
illness for more than 2 years, moderate
hyperproteinemia and hyperlipidemia.

Index
Hemoglobin	130.0 – 160.0 g/l 120.0 – 140 g/l
Red blood cells	4.0 – 5.0 x 10 12 /l 3.9 – 4.7 x 10 12 /l
Color index
Platelets	180.0 – 320.0 x 10 9 /l
Leukocytes Neutrophils Rod Segmented Eosinophils Basophils Lymphocytes Monocytes	4.0 – 9.0 x 10 9 /l
Erythrocyte sedimentation rate
Hematocrit

II. Etiological.

1. Infectious pericarditis:

viral (Coxsackie virus A9 and B1-4,
cytomegalovirus, adenovirus, virus
influenza, mumps, ECHO virus, HIV)

bacterial (staphylococcus, pneumococcus,
meningococcus, streptococcus, salmonella,
Mycobacterium tuberculosis, Corynobacter)

fungal (candidiasis, blastomycosis,
coccidioidosis)

other
infections (rickettsia, chlamydia,
toxoplasmosis, mycoplasmosis, actinomycosis)

2.
Ionizing radiation and massive
radiation therapy

3.
Malignant tumors (metastatic
lesions, less often primary
tumors)

4.
Diffuse
connective tissue diseases (RA,
SLE, periarteritis nodosa, syndrome
Reiter)

5. Systemic blood diseases
(hemoblastosis)

6. Pericarditis in diseases
with profound metabolic disorders
(gout, amyloidosis,
CRF with uremia, severe hypothyroidism,
diabetic ketoacidosis)

7.
Autoimmune processes (acute
rheumatic fever syndrome
Dressler after myocardial infarction and
open heart surgery, autoreactive
pericarditis)

8.
Allergic diseases (serum
illness, drug allergy)

9.
Side effects of some medications
agents (procainamide, hydralazine,
heparin, indirect anticoagulants,
minoxidil, etc.)

10.
Traumatic causes (thoracic injury
cells, surgical interventions in
chest cavity, cardiac probing,
esophageal rupture)

12. Idiopathic pericarditis

Constrictive pericarditis tuberculous
etiology. CHF stage IIA, IIFC.

Chapter VI. Gastroenterology peptic ulcer of the stomach and duodenum.

Classification of anemia by color
indicator is presented in Table 1.

Table 1

Classification.

generally accepted
classification of peptic ulcer is not
exists. From the point
from the point of view of nosological independence
distinguish between peptic ulcer and
symptomatic gastroduodenal
ulcers, as well as peptic ulcer disease,
associated and not associated
with Helicobacter pylori.

- stomach ulcers that occur within
gastropathy induced by taking
non-steroidal anti-inflammatory
drugs (NSAIDs);

- ulcers
duodenum;

- combined gastric and duodenal ulcers
intestines.

- exacerbation;

- scarring;

- remission;

- cicatricial ulcerative deformity of the stomach
and duodenum.

- single ulcers;

- multiple ulcers.

- small ulcers (up to 0.5 cm);

- medium (0.6 - 2.0 cm);

- large (2.0 – 3.0 cm);

- gigantic (more than 3.0 cm).

- acute (first diagnosed ulcerative
disease);

- rare - once every 2 - 3 years;

- frequent - 2 times a year or more often.

bleeding; penetration;
perforation; development of perivisceritis;
formation of cicatricial ulcerative stenosis
gatekeeper; malignancy of the ulcer.

Ulcerative
disease localized to a peptic ulcer
(1.0 cm) in the duodenal bulb
intestines, chronic course, exacerbation.
Scar-ulcerative deformation of the bulb
duodenum, I
Art.

Normal values ​​of laboratory parameters Peripheral blood parameters

Color index	Anemia
Normochromic	hemolytic anemia
	aplastic anemia
Hypochromic - CPU below 0.85	Iron-deficiency anemia
	sideroachrestic anemia
	thalassemia
	anemia in chronic diseases
Hyperchromic - CPU above 1.05:	vitamin B12 deficiency anemia
	folate deficiency anemia

Classification of anemia by degree
severity:

mild degree: Hb 110 – 90 g/l

moderate: Hb 89 – 70 g/l

severe: HB below 70 g/l

Main laboratory signs
ZhDA are:

low color index;

hypochromia of erythrocytes;

increase in total iron-binding
serum abilities, decreased levels
transferrin.

Chronic iron deficiency anemia,
moderate severity. Fibroids
uterus. Meno- and metrorrhagia.

Index	Units SI
Bilirubin general indirect	9,2-20,7 µmol/l
Serum iron blood	12.5-30.4 µmol/l
2) capillary blood 3) glucose tolerance test (capillary blood) in 120 minutes 4)glycosylated hemoglobin	4,2 — 6.1 mmol/l 3,88 — 5.5 mmol/l before 5.5 mmol/l before 7.8 mmol/l 4.0-5.2 molar %
Total cholesterol	(amp)lt; 5.0 mmol/l
Lipoproteins high density	(amp)gt; 1.0 mmol/l (amp)gt;1,2 mmol/l
Lipoproteins low density	(amp)lt;3.0 mmol/l
Coefficient atherogenicity
Triglycerides	(amp)lt; 1.7 mmol/l
Total protein
Protein fractions: albumin globulins α1-globulins α2-globulins β-globulins γ-globulins
Seromucoid
Thymol test

Carotid arteries.

Ultrasonic
examination of the carotid arteries with measurements
thickness of the intima-media complex (IMC) and
assessing the presence of plaques allows
predict both stroke and heart attack
myocardium, regardless of traditional
cardiovascular risk factors.
This is true for both CMM thickness values
at the level of the carotid artery bifurcation
(which mainly reflects atherosclerosis),
and for the CMM value at the general level
carotid artery (which mainly reflects
vascular hypertrophy).

Pulse wave speed.

Determined that
the phenomenon of stiffness of large arteries and
pulse wave reflections are
the most important pathophysiological
determinants of ISAH and increase
pulse pressure during aging.
Carotid-femoral pulse rate
waves (SPW) are the “gold standard”
aortic stiffness measurements.

IN
recently issued conciliation
statement this threshold value was
adjusted to 10 m/sec, taking into account
immediate distance from sleepy
to the femoral arteries and taking into
attention 20% shorter true
anatomical distance, which
a pressure wave passes through (i.e., 0.8 x 12 m/sec
or 10 m/sec).

Ankle-brachial index.

Ankle-brachial
index (ABI) can be measured either
automatically, using instruments, or
using a Doppler meter with continuous
wave and a sphygmomanometer to measure
HELL. Low ABI ((amp)lt;0.9) indicates impairment
peripheral arteries and on pronounced
atherosclerosis in general is a predictor
cardiovascular events and associated
with approximately double magnification
cardiovascular mortality and incidence
major coronary events, compared
with general indicators in each
Framingham risk category.

Table 8

Arterial hypertension in combination with chronic heart failure.

IN
as initial therapy for hypertension should
ACE inhibitors, beta blockers, diuretics should be recommended
and aldosterone receptor blockers.
In the SOLVD study
and CONSENSUS
ability has been reliably proven
original enalapril increase
survival of patients with LV dysfunction
and CHF. Only in case of insufficient
antihypertensive effect may be
Calcium antagonists (CA) are prescribed
dihydropyridine series. Non-dihydropyridine
AKs are not used due to the possibility
deterioration of contractility
myocardium and increased symptoms of CHF.

For asymptomatic
course of the disease and LV dysfunction
ACE inhibitors and beta blockers are recommended.

AG
with kidney damage. AG is decisive
any factor in the progression of chronic renal failure
etiology; adequate blood pressure control
slows down its development. Special attention
nephroprotection should be given to
diabetic nephropathy. Necessary
achieve strict blood pressure control (amp)lt;
130/80 mmHg and reduction of proteinuria
or albinuria to values ​​close to
normal.

To reduce
proteinuria, the drugs of choice are
ACEI or ARB.

For
achieving target blood pressure levels at
kidney damage is often used
combination therapy with the addition
diuretic (if nitrogen excretion is impaired
renal function - loop diuretic), and
also AK.

U
patients with kidney damage, taking into account
increased risk of developing cardiovascular complications often
complex therapy is indicated -
antihypertensive drugs, statins,
antiplatelet agents, etc.

Cockcroft-Gault formula

CF = [ (140-age) x
body weight (kg) x 0.85 (for women
)]

____________________________________________

[ 814* × creatinine
serum (mmol/l)].

* — When measuring level
blood creatinine in mg/dl in this formula
instead of coefficient 814 is used
72.

table 2

Ag and pregnancy.

SBP ≥140 mmHg. and DBP ≥90 mm Hg.
Elevated blood pressure must be confirmed
at least two dimensions. Measurement
should be performed on both hands.
Pressure on the right and left arms, like
usually varies. Should choose
hand with a higher value
blood pressure and further
measure arterial
pressure on this hand.

SBP value
determined by the first of two
successive tones. In the presence of
auscultatory failure may occur
underestimation of blood pressure figures.
The DBP value is determined by Y
phase of Korotkoff sounds, it is more accurate
corresponds to intra-arterial
pressure. Difference between DBP according to IY
and Y
phase may be clinically significant.

Also, don't round
resulting numbers up to 0 or 5, measurement
should be produced up to 2 mmHg. Art., for
what needs to be released slowly
air from the cuff. Measurement
pregnant women must be taken in
sitting position. Lying down
compression of the inferior vena cava may
distort blood pressure numbers.

Distinguish
3 types of hypertension in pregnant women, their
differential diagnosis is not always
simple, but necessary to determine
treatment strategies and risk levels for
pregnant woman and fetus.

table 2

Prevalence
different types of arterial hypertension
in pregnant women

Term
"chronic essential hypertension"
should apply to those
women who have had elevated blood pressure
registered before 20 weeks,
Moreover, secondary causes of hypertension are excluded.

Arterial
hypertension that developed between the ages of 20
weeks of pregnancy to 6 weeks after
childbirth is considered directly
caused by pregnancy and
detected in approximately 12% of women.

Preeclampsia
called a combination of arterial
hypertension and proteinuria, for the first time
detected after 20 weeks of pregnancy.
However, we must remember that this pathological
the process can occur without proteinuria,
but with the presence of other symptoms (defeat
nervous system, liver, hemolysis, etc.).

The concept of “gestational hypertension”
refers to an isolated increase
Blood pressure in the second half of pregnancy.
The diagnosis can only be made
retrospectively, after
pregnancy can be resolved, and
signs such as proteinuria, and
also no other violations were found
will. Compared to chronic
arterial hypertension and preeclampsia,
prognosis for the woman and fetus with
gestational hypertension most
favorable

IN
first two trimesters of pregnancy
all are contraindicated for use
antihypertensive drugs, except
methyldopa. In the third trimester of pregnancy
possible use of cardioselective
BAB. SBP (amp)gt;170 DBP (amp)gt;119 mmHg. in a pregnant woman
women is regarded as a crisis and is
indication for hospitalization. For
intravenous therapy should be used
labetalol, for oral use - methyldopa
or nifedipine.

Strictly
ACE inhibitors and ARBs are contraindicated
in connection with the possible development of congenital
deformities and fetal death.

Multiple myeloma.

Clinical and anatomical
classification
based on X-ray data
skeletal and morphological studies
analysis of punctates and trepanates of bones,
MRI and CT data. There are diffuse-focal
form, diffuse, multifocal,
and rare forms (sclerosing),
predominantly visceral). Stages
multiple myeloma (MM) are presented
in the table.

Refractory ag.

Refractory
or treatment resistant is considered
Hypertension for which the prescribed treatment is
lifestyle changes and rational
combined antihypertensive
therapy using adequate doses
at least three drugs, including
diuretics, does not lead to sufficient
reducing blood pressure and achieving its target
level.

In such cases, detailed
OM examination because with refractory
AH in them is often observed pronounced
changes. it is necessary to exclude secondary
forms of hypertension that cause
refractoriness to antihypertensive
treatment. Inadequate doses of antihypertensive drugs
drugs and their irrational combinations
may lead to insufficient reduction
HELL.

Basic
causes of treatment-refractory hypertension
are presented in Table 3.

Table
3.

Causes of refractory
arterial hypertension

	Not identified secondary forms of hypertension;
	Absence adherence to treatment;
	Continued taking medications that increase HELL
	Overload volume, due to the following reasons: inadequate therapy diuretics, progression of chronic renal failure, excessive consumption of food salt
Pseudo-resistance:
	Isolated office hypertension (“white blood pressure”) robe")
	Usage when measuring blood pressure cuff inappropriate size

Emergency conditions

All
situations that, to one degree or another,
dictate a rapid decrease in blood pressure, subdivide
for 2 large groups.

States,
requiring emergency treatment – ​​reduction
Blood pressure during the first minutes and hours at
with the help of parentally administered drugs.

Urgent
therapy is necessary for such an increase
blood pressure, which leads to the appearance or
worsening symptoms from OM:
unstable angina, myocardial infarction, acute
LV failure dissecting
aortic aneurysm, eclampsia, MI, edema
optic nerve nipple. Immediate
a decrease in blood pressure is indicated in cases of central nervous system injury, in
postoperative patients, in case of threat
bleeding, etc.

Vasodilators

Nitroprusside
sodium (may increase intracranial
pressure);

Nitroglycerine
(preferred for myocardial ischemia);

• 
  (preferred in the presence of CHF)

Antiadrenergic
facilities
(phentolamine for suspected
pheochromocytoma).

Diuretics
(furosemide).

Ganglioblockers
(pentamine)

Neuroleptics
(droperidol)

HELL
should be reduced by 25% in the first 2 hours
and up to 160/100 mm Hg. over the next
2-6 hours. Do not lower blood pressure too much
quickly to avoid ischemia of the central nervous system and kidneys
and myocardium. At blood pressure (amp)gt;180/120 mm Hg. his
should be measured every 15-30 minutes.

States,
requiring a decrease in blood pressure over several
hours. Self
in itself a sharp increase in blood pressure, not
accompanied by symptoms
from other organs, dictates
mandatory but not so urgent
intervention and can be stopped
oral medications with
relatively fast acting: BAB,
AK (nifedipine), clonidine, short-acting
ACE inhibitors (captopril), loop diuretics,
prazosin.

Treatment
a patient with uncomplicated GC may
carried out on an outpatient basis.

TO
number of conditions requiring relatively
urgent intervention refers
malignant
AG.

At
malignant hypertension is observed extremely
high blood pressure (DBP (amp)gt; 120 mm Hg) with the development
pronounced changes from
vascular wall, which leads to ischemia
tissues and organ dysfunction. IN
development of malignant hypertension takes
involvement of multiple hormonal systems,
activation of their activity causes
increased natriuresis, hypovolemia, and
also damages the endothelium and proliferates
SMC intima.

Syndrome
malignant hypertension is usually accompanied
progression of chronic renal failure, deterioration
vision, weight loss, symptoms
Central nervous system, changes in rheological properties
blood up to the development of DIC syndrome,
hemolytic anemia.

For patients
treatment is indicated for malignant hypertension
a combination of three or more antihypertensive drugs
drugs.

At
in the treatment of severe hypertension, one should remember
possibility of excess excretion from
body sodium, with intense
prescription of diuretics, which is accompanied
further activation of the RAAS and increased
HELL.

Sick
with malignant hypertension should still be
times thoroughly examined for
presence of secondary hypertension.

Risk factors for CKD.

Factors risk

Options

Fatal Removable

Chronic kidney disease (especially with ESRD) among relatives Low birth weight (“absolute oligonephronia”) Race (highest in African Americans) Elderly age Low socioeconomic status Arterial hypertension Obesity Insulin resistance/type 2 diabetes Lipoprotein metabolism disorder (hypercholesterolemia, hypertriglyceridemia, increase in LDL concentration) Metabolic syndrome Cardiovascular diseases systems Taking certain medications drugs HBV-, HCV-, HIV infection

History of kidney damage;

Polyuria with nocturia;

Reduction in kidney size
according to ultrasound or x-ray
research;

Azotemia;

Reduced relative density and
urine osmolarity;

Decreased GFR (less than 15 ml/min);

Normochromic anemia;

Hyperkalemia;

Hyperphosphatemia in combination with
hypocalcemia.

Diagnosis criteria.

A)
acute fever at the onset of the disease
(to(amp)gt;38.0°C);

b) cough with sputum;

V)
objective signs (shortening
percussion sound, focus of crepitus
and/or fine bubbling rales, hard
bronchial breathing);

G)
leukocytosis (amp)gt; 10x109/l
and/or band shift ((amp)gt;10%).

Absence
or unavailability of x-ray
confirmation of focal infiltration
in the lungs (radiography or large-frame
fluorography of the chest organs)
makes the diagnosis of CAP inaccurate/uncertain.
In this case, the diagnosis of the disease is based
based on epidemiological data
history, complaints and related
local symptoms.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)

Essential [primary] hypertension (I10)

general information

Short description

Arterial hypertension- stable increase in systolic blood pressure of 140 mm Hg. or more and/or diastolic blood pressure of 90 mm Hg or more as a result of at least three measurements taken at different times in a quiet environment. The patient should not take medications that either increase or decrease blood pressure (1).

Protocol code: P-T-001 "Arterial hypertension"

Profile: therapeutic

Stage: PHC

ICD-10 code(s): I10 Essential (primary) hypertension

Classification

WHO/IAS 1999

1. Optimal blood pressure< 120 / 80 мм рт.ст.

2. Normal blood pressure<130 / 85 мм рт.ст.

3. High normal blood pressure or prehypertension 130 - 139 / 85-89 mm Hg.

AG degrees:

1. Degree 1 - 140-159 / 90-99.

2. Degree 2 - 160-179/100-109.

3. Grade 3 - 180/110.

4. Isolated systolic hypertension - 140/<90.

Risk factors and groups

Criteria for stratification of hypertension

Cardiovascular risk factors vascular diseases	Organ damage targets	Related (associated) clinical conditions
1.Used for risk stratification: The value of SBP and DBP (grade 1-3); Age; Men >55 years old; Women > 65 years old; Smoking; General level blood cholesterol > 6.5 mmol/l; Diabetes; Familial cases of early development of cardiovascular diseases 2. Other factors unfavorable influencing the prognosis*: Reduced level HDL cholesterol; Increased level LDL cholesterol; Microalbuminuria (30-300 mg/day) at diabetes mellitus; Violation of tolerance to glucose; Obesity; Passive lifestyle; Increased level fibrinogen in the blood; Socio-economic groups high risk; Geographical region high risk	Left hypertrophy ventricle (ECG, EchoCG, radiography); Proteinuria and/or slight increase plasma creatinine (106 - 177 µmol/l); Ultrasonic or X-ray signs atherosclerotic lesions of the sleepy iliac and femoral arteries, aorta; Generalized or focal narrowing of the arteries retina;	Cerebrovascular diseases: Ischemic stroke; Hemorrhagic stroke; Transitional ischemic attack Heart diseases: Myocardial infarction; Angina; Revascularization coronary vessels; Congestive heart failure Kidney diseases: Diabetic nephropathy; Kidney failure (creatinine > 177); Vascular diseases: Dissecting aneurysm; Peripheral damage arteries with clinical manifestations Expressed hypertensive retinopathy: Hemorrhages or exudates; Swelling of the nipple optic nerve

*Additional and “new” risk factors (not taken into account when risk stratification).

Risk levels of hypertension:

1. Low risk group (risk 1). This group includes men and women under the age of 55 years with stage 1 hypertension in the absence of other risk factors, target organ damage and associated cardiovascular diseases. The risk of developing cardiovascular complications in the next 10 years (stroke, heart attack) is less than 15%.

2. Medium risk group (risk 2). This group includes patients with grade 1 or 2 hypertension. The main sign of belonging to this group is the presence of 1-2 other risk factors in the absence of target organ damage and associated cardiovascular diseases. The risk of developing cardiovascular complications in the next 10 years (stroke, heart attack) is 15-20%.

3. High-risk group (risk 3). This group includes patients with grade 1 or 2 hypertension who have 3 or more other risk factors or target organ damage. The same group includes patients with grade 3 hypertension without other risk factors, without target organ damage, without associated diseases and diabetes mellitus. The risk of developing cardiovascular complications in this group over the next 10 years ranges from 20 to 30%.

4. Very high risk group (risk 4). This group includes patients with any degree of hypertension with associated diseases, as well as patients with grade 3 hypertension with the presence of other risk factors and/or target organ damage and/or diabetes mellitus, even in the absence of associated diseases. The risk of developing cardiovascular complications in the next 10 years exceeds 30%.

Risk stratification for assessing the prognosis of patients with hypertension

Other risk factors* (except for hypertension), lesions target organs, associated diseases	Blood pressure, mm Hg.
	Degree 1 GARDEN 140-159 DBP 90-99	Degree 2 GARDEN 160-179 DBP 100-109	Degree 3 SBP >180 DBP >110
I. There are no risk factors, target organ damage, associated diseases	Low risk	Medium risk	High risk
II. 1-2 risk factors	Medium risk	Medium risk	Very tall risk
III. 3 risk factors and over and/or defeat target organs	High risk	High risk	Very tall risk
IV. Associates (related) clinical conditions and/or diabetes	Very tall risk	Very tall risk	Very tall risk

Diagnostics

Diagnostic criteria

Complaints and anamnesis

In a patient with newly diagnosed hypertension, it is necessary careful collection of anamnesis, which should include:

- duration of existence of hypertension and levels of increased blood pressure in the anamnesis, as well as the results of previously used treatment with antihypertensive drugs,

A history of hypertensive crises;

- data on the presence of symptoms of coronary artery disease, heart failure, central nervous system diseases, peripheral vascular lesions, diabetes mellitus, gout, lipid metabolism disorders, broncho-obstructive diseases, kidney diseases, sexual disorders and other pathologies, as well as information on medications used to treat these diseases , especially those that can increase blood pressure;

- identification of specific symptoms that would give reason to assume the secondary nature of hypertension (young age, tremor, sweating, severe treatment-resistant hypertension, murmur over the renal arteries, severe retinopathy, hypercreatininemia, spontaneous hypokalemia);

- in women - gynecological history, connection of increased blood pressure with pregnancy, menopause, taking hormonal contraceptives, hormone replacement therapy;

- a thorough assessment of lifestyle, including consumption of fatty foods, table salt, alcoholic beverages, quantitative assessment of smoking and physical activity, as well as data on changes in body weight throughout life;

- personal and psychological characteristics, as well as environmental factors that could influence the course and outcome of treatment of hypertension, including marital status, situation at work and in the family, level of education;

- family history of hypertension, diabetes mellitus, lipid metabolism disorders, coronary heart disease (CHD), stroke or kidney disease.

Physical examination:

1. Confirming the presence of hypertension and establishing its stability (an increase in blood pressure above 140/90 mm Hg in patients who do not receive regular antihypertensive therapy as a result of at least three measurements in different settings).

2. Exclusion of secondary arterial hypertension.

3. Risk stratification of hypertension (determining the degree of increase in blood pressure, identifying avoidable and irreducible risk factors, target organ damage and associated conditions).

Laboratory research: hemoglobin, red blood cells, fasting blood glucose, total cholesterol, HDL cholesterol, fasting triglycerides, uric acid, creatinine, potassium, sodium, urinalysis.

Instrumental studies: echocardiography, ultrasound of the carotid and femoral arteries, ultrasound of the kidneys, Doppler ultrasound of the renal vessels, ultrasound of the adrenal glands, radioisotope renography.

Indications for specialist consultation: according to indications.

Differential diagnosis: no.

List of main diagnostic measures:

1. Assessment of medical history (family history of hypertension, kidney disease, early development of coronary artery disease in close relatives; indication of a stroke, myocardial infarction; hereditary predisposition to diabetes mellitus, lipid metabolism disorders).

2. Assessment of lifestyle (nutrition, consumption of table salt, physical activity), nature of work, marital status, family environment, psychological characteristics of the patient.

3. Examination (height, body weight, body mass index, type and degree of obesity if present, identification of signs of symptomatic hypertension - endocrine stigmas).

4. Measure blood pressure repeatedly under different conditions.

5. ECG in 12 leads.

6. Fundus examination.

7. Laboratory examination: hemoglobin, red blood cells, fasting blood glucose, total cholesterol, HDL cholesterol, fasting triglycerides, uric acid, creatinine, potassium, sodium, urinalysis.

8. Due to the high prevalence of hypertension in the population, screening for the disease should be performed as part of routine examination for other conditions.

9. Screening for hypertension is especially indicated in individuals with risk factors: a family history of hypertension, hyperlipidemia, diabetes mellitus, smoking, obesity.

10. In persons without clinical manifestations of hypertension, annual blood pressure measurements are required. Further frequency of blood pressure measurements is determined by the initial indicators.

List of additional diagnostic measures

As additional instrumental and laboratory tests, if necessary - echocardiography, ultrasound of the carotid and femoral arteries, ultrasound of the kidneys, Doppler ultrasound of the renal vessels, ultrasound of the adrenal glands, radioisotope renography, C-reactive protein in the blood by quantitative method, microalbuminuria test strips (required for diabetes mellitus) diabetes), quantitative proteinuria, urine analysis according to Nechiporenko and Zimnitsky, Rehberg test.

Treatment

Treatment tactics

Treatment goals:

1. The goal of treatment is to reduce blood pressure to the target level (in young and middle-aged patients - below< 130 / 85, у пожилых пациентов - < 140 / 90, у больных сахарным диабетом - < 130 / 85). Даже незначительное снижение АД при терапии необходимо, если невозможно достигнуть «целевых» значений АД. Терапия при АГ должна быть направлена на снижение как систолического, так и диастолического артериального давления.

2. Prevention of the occurrence of structural and functional changes in target organs or their reverse development.

3. Prevention of the development of cerebrovascular accidents, sudden cardiac death, heart and kidney failure and, as a result, improved long-term prognosis, i.e. patient survival.

Non-drug treatment

Changing the patient's lifestyle

1. Non-drug treatment should be recommended for all patients with hypertension, including those who require drug therapy.

2. Non-drug therapy reduces the need for drug therapy and increases the effectiveness of antihypertensive drugs.

6. Patients with excess body weight (BMI: 25.0 kg/m2) should be advised to lose weight.

7. It is necessary to increase physical activity through regular exercise.

8. The consumption of table salt should be reduced to a level of less than 5-6 g per day or sodium to a level of less than 2.4 g per day.

9. The consumption of fruits and vegetables should be increased, and foods containing saturated fatty acids should be reduced.

Drug treatment:

1. Use drug therapy promptly in patients at “high” and “very high” risk for cardiovascular events.

2. When prescribing drug therapy, take into account the indications and contraindications for their use, as well as the cost of drugs.

4. Start therapy using minimal doses of drugs to avoid side effects.

Basic antihypertensive drugs

Of the six groups of antihypertensive drugs currently used, the most proven effectiveness is thiazide diuretics and β-blockers. Drug therapy should be started with low doses of thiazide diuretics, and in the absence of effectiveness or poor tolerability, with β-blockers.

Diuretics

Thiazide diuretics are recommended as first-line drugs for the treatment of hypertension. To avoid side effects, low doses of thiazide diuretics should be prescribed. The optimal dose of thiazide and thiazide-like diuretics is the minimum effective dose, corresponding to 12.5-25 mg of hydrochloride. Diuretics in very low doses (6.25 mg hydrochloride or 0.625 mg indapamide) increase the effectiveness of other antihypertensive agents without undesirable metabolic changes.

Hydrochlorbiazide orally at a dose of 12.5-25 mg in the morning for a long time. Indapamide orally 2.5 mg (long-acting form 1.5 mg) once in the morning for a long time.

Indications for the use of diuretics:

1. Heart failure.

2. Hypertension in old age.

3. Systolic hypertension.

4. Hypertension in people of the Negroid race.

5. Diabetes mellitus.

6. High coronary risk.

Contraindications to the use of diuretics: gout.

Possible contraindications to the use of diuretics: pregnancy.

Rational combinations:

1. Diuretic + β-blocker (hydrochlorothiazide 12.5-25 mg or indapamide 1.5; 2.5 mg + metoprolol 25-100 mg).

2. Diuretic + ACEI (hydrochlorothiazide 12.5-25 mg or indapamide 1.5; 2.5 mg + enalapril 5-20 mg or lisinopril 5-20 mg or perindopril 4-8 mg. It is possible to prescribe fixed combination drugs - enalapril 10 mg + hydrochlorothiazide 12.5 and 25 mg, as well as a low-dose fixed combination drug - perindopril 2 mg + indapamide 0.625 mg).

3. Diuretic + AT1 receptor blocker (hydrochlorothiazide 12.5-25 mg or indapamide 1.5; 2.5 mg + eprosartan 600 mg). Eprosartan is prescribed at a dose of 300-600 mg/day. depending on blood pressure level.

β-blockers

Indications for the use of β-blockers:

1. β-blockers can be used as an alternative to thiazide diuretics or as part of combination therapy in the treatment of elderly patients.

2. Hypertension in combination with angina pectoris, previous myocardial infarction.

3. Hypertension + heart failure (metoprolol).

4. Hypertension + type 2 diabetes.

5. Hypertension + high coronary risk.

6. Hypertension + tachyarrhythmia.

Metoprolol orally, initial dose 50-100 mg/day, usual maintenance dose 100-200 mg/day. in 1-2 doses.

Contraindications to the use of β-blockers:

2. Bronchial asthma.

3. Obliterating vascular diseases.

4. AV blockade of II-III degree.

Possible contraindications to the use of β-blockers:

1. Athletes and physically active patients.

2. Peripheral vascular diseases.

3. Impaired glucose tolerance.

Rational combinations:

1. BAB + diuretic (metoprolol 50-100 mg + hydrochlorothiazide 12.5-25 mg or indapamide 1.5; 2.5 mg).

2. BAB + AK of the dihydropyridine series (metoprolol 50-100 mg + amlodipine 5-10 mg).

3. BAB + ACEI (metoprolol 50-100 mg + enalapril 5-20 mg or lisinopril 5-20 mg or perindopril 4-8 mg).

4. Beta blocker + AT1 receptor blocker (metoprolol 50-100 mg + eprosartan 600 mg).

5. Beta blocker + α-blocker (metoprolol 50-100 mg + doxazosin 1 mg for hypertension due to prostate adenoma).

Calcium channel blockers (calcium antagonists)

Long-acting calcium antagonists of the dihydropyridine derivative group can be used as an alternative to thiazide diuretics or as part of combination therapy.
It is necessary to avoid prescribing short-acting calcium antagonists of the group of dihydropyridine derivatives for long-term blood pressure control.

Indications for the use of calcium antagonists:

1. Hypertension in combination with exertional angina.

2. Systolic hypertension (long-acting dihydropyridines).

3. Hypertension in elderly patients.

4. Hypertension + peripheral vasculopathy.

5. Hypertension + carotid atherosclerosis.

6. Hypertension + pregnancy.

7. AH + DM.

8. Hypertension + high coronary risk.

Dihydropyridine calcium antagonist - amlodipine orally at a dose of 5-10 mg once a day.

Calcium antagonist from the phenylalkylamine group - verapamil orally 240-480 mg in 2-3 doses, long-acting drugs 240-480 mg in 1-2 doses.

Contraindications to the use of calcium antagonists:

1. II-III degree AV block (verapamil and diltiazem).

2. CH (verapamil and diltiazem).

Possible contraindications to the use of calcium antagonists: tachyarrhythmias (dihydropyridines).

ACE inhibitors

Indications for the use of ACE inhibitors:

1. Hypertension in combination with heart failure.

2. Hypertension + LV contractile dysfunction.

3. Post-MI.

5. Hypertension + diabetic nephropathy.

6. Hypertension + non-diabetic nephropathy.

7. Secondary prevention of strokes.

8. Hypertension + High coronary risk.

Enalapril orally, in monotherapy, the initial dose is 5 mg 1 time per day, in combination with diuretics, in the elderly or with impaired renal function - 2.5 mg 1 time per day, the usual maintenance dose is 10-20 mg, the highest daily dose is 40 mg.

Lisinopril orally, in monotherapy, the initial dose is 5 mg 1 time per day, the usual maintenance dose is 10-20 mg, the highest daily dose is 40 mg.

Perindopril, in monotherapy, the initial dose is 2-4 mg 1 time per day, the usual maintenance dose is 4-8 mg, the highest daily dose is 8 mg.

Contraindications to the use of ACE inhibitors:

1. Pregnancy.

2. Hyperkalemia.

3. Bilateral renal artery stenosis

Angiotensin II receptor antagonists (it is proposed to include in the list of vital drugs a drug from the group of AT1 receptor blockers - eprosartan, as a drug of choice in patients intolerant to ACEIs and in the combination of hypertension with diabetic nephropathy).
Eprosartan is prescribed at a dose of 300-600 mg/day. depending on blood pressure level.

Indications for the use of angiotensin II receptor antagonists:

1. Hypertension + ACEI intolerance (cough).

2. Diabetic nephropathy.

3. AH + DM.

4. AG + CH.

5. Hypertension + non-diabetic nephropathy.

6. LV hypertrophy.

Contraindications to the use of angiotensin II receptor antagonists:

1. Pregnancy.

2. Hyperkalemia.

3. Bilateral renal artery stenosis.

Imidazoline receptor agonists

Indications for the use of imidazoline receptor agonists:

1. Hypertension + metabolic syndrome.

2. AH + DM.

(It is proposed to include a drug of this group in the list of vital drugs - moxonidine 0.2-0.4 mg/day).

Possible contraindications to the administration of imidozoline receptor agonists:

1. AV blockade of II-III degree.

2. Hypertension + severe heart failure.

Antiplatelet therapy

For the primary prevention of serious cardiovascular complications (MI, stroke, vascular death), acetylsalicylic acid is indicated for patients at a dose of 75 mg/day. with a risk of their occurrence - 3% per year or >10% over 10 years. In particular, candidates are patients over 50 years of age with controlled hypertension, in combination with end-organ damage and/or diabetes and/or other risk factors for an unfavorable outcome in the absence of a bleeding tendency.

Lipid-lowering drugs (atorvastatin, simvastatin)

Their use is indicated in people with a high probability of myocardial infarction, death from coronary heart disease or atherosclerosis of other localization due to the presence of multiple risk factors (including smoking, hypertension, the presence of early coronary artery disease in the family), when a diet low in animal fats was ineffective (lovastatin , pravastatin).

Sources and literature

1. Protocols for diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
   1. 1. Essential hypertension. Guidelines for clinical care. University of Michigan Health system. 2002 2. VHA/DOD Clinical practice guideline for diagnosis and management of hypertension in the primary care setting. 1999. 3. Prodigy guidance. Hypertension. 2003. 4. Management of hypertension in adults in primary care. National institute for clinical excellence. 2004 5. Guidelines and protocols. Detection and diagnosis of hypertension. British Columbia medical association. 2003 6. Michigan quality improvement consortium. Medical management of adults with essential hypertension. 2003 7. Arterial hypertension. Seventh Report of the Joint Commission on the Detection and Treatment of Arterial Hypertension, supported by the National Heart, Lung, and Blood Institute. 2003. 8. European Society of Arterial Hypertension European Society of Cardiology 2003. recommendations for the diagnosis and treatment of arterial hypertension. J.hypertension 2003;21:1011-53 9. Clinical guidelines plus pharmacological formulary. I.N. Denisov, Yu.L. Shevchenko.M.2004. 10. The 2003 Canadian Recommendations for the management of hypertension diagnosis. 11. The Seventh Report of the Joint national Committee on prevention, Detection, Evaluation and treatment of high blood pressure. 2003. 12. Okorokov A.N. Diagnosis of diseases of internal organs, volume 7. 13. Kobalava Zh.D., Kotovskaya Yu.V. Arterial hypertension 2000: key aspects of diagnosis and differential. Diagnostics, prevention. Clinics and treatments. 14. Federal guidelines for the use of medicines (formulary system). Issue 6. Moscow, 2005.

Information

Rysbekov E.R., Research Institute of Cardiology and Internal Diseases of the Ministry of Health of the Republic of Kazakhstan.

Attached files

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The word “hypertension” means that the human body had to increase blood pressure for some purpose. Depending on the conditions that can cause this condition, there are types of hypertension, and each of them is treated in its own way.

Classification of arterial hypertension, taking into account only the cause of the disease:

1. Its cause cannot be identified by examining those organs whose disease requires the body to increase blood pressure. It is because of an unclear reason that it is called essential or idiopathic(both terms translate as "unclear cause"). Domestic medicine calls this type of chronic increase in blood pressure hypertension. Due to the fact that this disease will have to be reckoned with all your life (even after the pressure returns to normal, you will need to follow certain rules so that it does not increase again), in popular circles it is called chronic hypertension, and it is this that is divided into the degrees, stages and risks discussed below.
2. - one for which the cause can be identified. It has its own classification - according to the factor that “triggered” the mechanism of increasing blood pressure. We'll talk about this below.

Both primary and secondary hypertension are divided according to the type of increase in blood pressure. So, hypertension can be:

There is also a classification based on the nature of the disease. It divides both primary and secondary hypertension into:

According to another definition, malignant hypertension is an increase in blood pressure to 220/130 mmHg. Art. and more, when the ophthalmologist detects grade 3-4 retinopathy in the fundus (hemorrhages, retinal edema or optic nerve edema and vasoconstriction, and a kidney biopsy diagnoses “fibrinoid arteriolonecrosis.”

Symptoms of malignant hypertension are headaches, spots before the eyes, pain in the heart, and dizziness.

Before this we wrote “upper”, “lower”, “systolic”, “diastolic” pressure, what does this mean?

Systolic (or “upper”) pressure is the force with which blood presses on the walls of large arterial vessels (that’s where it is thrown out) during compression of the heart (systole). Essentially, these arteries, with a diameter of 10-20 mm and a length of 300 mm or more, must “squeeze” the blood that is thrown into them.

Only systolic pressure increases in two cases:

• when the heart pumps out a large amount of blood, which is typical for hyperthyroidism, a condition in which the thyroid gland produces an increased amount of hormones that cause the heart to contract strongly and frequently;
• when the elasticity of the aorta is reduced, which is observed in older people.

Diastolic (“lower”) is the pressure of fluid on the walls of large arterial vessels that occurs during relaxation of the heart - diastole. In this phase of the cardiac cycle, the following occurs: large arteries must transfer the blood entering them during systole to arteries and arterioles of smaller diameter. After this, the aorta and large arteries need to prevent overload of the heart: while the heart relaxes, accepting blood from the veins, the large vessels must have time to relax in anticipation of its contraction.

The level of arterial diastolic pressure depends on:

1. The tone of such arterial vessels (according to Tkachenko B.I. “ Normal human physiology." - M, 2005), which are called vessels of resistance:
   • mainly those that have a diameter of less than 100 micrometers, arterioles are the last vessels before the capillaries (these are the smallest vessels from where substances penetrate directly into the tissues). They have a muscular layer of circular muscles, which are located between various capillaries and are a kind of “faucets”. Switching these “faucets” determines which part of the organ will now receive more blood (that is, nutrition), and which will receive less;
   • to a small extent, the tone of the medium and small arteries (“distribution vessels”), which carry blood to the organs and are located inside the tissues, plays a role;
2. Heart contraction rates: if the heart contracts too often, the vessels do not yet have time to deliver one portion of blood before the next one arrives;
3. The amount of blood that is included in the blood circulation;
4. Blood viscosity.

Isolated diastolic hypertension is very rare, mainly in diseases of the resistance vessels.

Most often, both systolic and diastolic pressure increase. This happens as follows:

When the heart begins to work against increased pressure, pushing blood into vessels with a thickened muscle wall, its muscle layer also increases (this is a common property for all muscles). This is called hypertrophy, and affects mainly the left ventricle of the heart, because it communicates with the aorta. There is no concept of “left ventricular hypertension” in medicine.

Primary arterial hypertension

The official widespread version says that the causes of primary hypertension cannot be found out. But physicist V.A. Fedorov and a group of doctors explained the increase in pressure by the following factors:

Carefully studying the mechanisms of the body, V.A. Fedorov with the doctors we saw that the vessels cannot nourish every cell of the body - after all, not all cells are close to the capillaries. They realized that cell nutrition is possible thanks to microvibration - a wave-like contraction of muscle cells, which make up more than 60% of body weight. These, described by academician Arinchin N.I., ensure the movement of substances and the cells themselves in the aqueous environment of the intercellular fluid, making it possible to provide nutrition, remove waste substances during the life process, and carry out immune reactions. When microvibration in one or several areas becomes insufficient, a disease occurs.

In their work, muscle cells that create microvibration use electrolytes present in the body (substances that can conduct electrical impulses: sodium, calcium, potassium, some proteins and organic substances). The balance of these electrolytes is maintained by the kidneys, and when the kidneys become diseased or the volume of working tissue in them decreases with age, microvibration begins to be lacking. The body tries as best it can to eliminate this problem by increasing blood pressure so that more blood flows to the kidneys, but because of this the whole body suffers.

Microvibration deficiency can lead to the accumulation of damaged cells and decay products in the kidneys. If they are not removed from there for a long time, they are transferred to the connective tissue, that is, the number of working cells decreases. Accordingly, the performance of the kidneys decreases, although their structure does not suffer.

The kidneys themselves do not have their own muscle fibers and receive microvibration from neighboring working muscles of the back and abdomen. Therefore, physical activity is necessary primarily to maintain the tone of the muscles of the back and abdomen, which is why correct posture is necessary even in a sitting position. According to V.A. Fedorov, “constant tension of the back muscles with correct posture significantly increases the saturation of internal organs with microvibration: kidneys, liver, spleen, improving their functioning and increasing the body’s resources. This is a very important circumstance that increases the importance of posture.” (" - Vasiliev A.E., Kovelenov A.Yu., Kovlen D.V., Ryabchuk F.N., Fedorov V.A., 2004)

A way out of the situation may be to provide additional microvibration (optimally in combination with thermal effects) to the kidneys: their nutrition is normalized, and they return the electrolyte balance of the blood to the “original settings.” Hypertension is thus resolved. At its initial stage, such treatment is enough to naturally lower blood pressure, without taking additional medications. If a person’s disease has “progressed far” (for example, it is grade 2-3 and the risk is 3-4), then the person may not be able to cope without taking medications prescribed by a doctor. At the same time, the message of additional microvibration will help reduce the doses of medications taken, and therefore reduce their side effects.

• in 1998 - at the Military Medical Academy named after. S.M.Kirova, St. Petersburg (“ . »)
• in 1999 - on the basis of the Vladimir Regional Clinical Hospital (“ " And " »);
• in 2003 - at the Military Medical Academy named after. CM. Kirov, St. Petersburg (“ . »);
• in 2003 - on the basis of the State Medical Academy named after. I.I. Mechnikova, St. Petersburg (“ . »)
• in 2009 - in the boarding house for labor veterans No. 29 of the Department of Social Protection of the Population of Moscow, Moscow Clinical Hospital No. 83, clinic of the Federal State Medical Center named after. Burnazyan FMBA of Russia (“” Dissertation of candidate of medical sciences Svizhenko A. A., Moscow, 2009).

Types of secondary arterial hypertension

Secondary arterial hypertension occurs:

1. (arising from a disease of the nervous system). It is divided into:
   • centrogenic – it occurs due to disturbances in the functioning or structure of the brain;
   • reflexogenic (reflex): in a certain situation or with constant irritation of the organs of the peripheral nervous system.
2. (endocrine).
3. – occurring when organs such as the spinal cord or brain suffer from a lack of oxygen.
4. , it also has its division into:
   • renovascular, when the arteries that bring blood to the kidneys narrow;
   • renoparenchymatous, associated with damage to kidney tissue, which is why the body needs to increase blood pressure.
5. (caused by blood diseases).
6. (due to a change in the “route” of blood movement).
7. (when it was caused by several reasons).

Let's tell you a little more.

The main command to large vessels, causing them to contract, increasing blood pressure, or relax, decreasing it, comes from the vasomotor center, which is located in the brain. If its work is disrupted, centrogenic hypertension develops. This can happen due to:

1. Neuroses, that is, diseases when the structure of the brain does not suffer, but under the influence of stress a focus of excitation is formed in the brain. It involves the main structures that “include” an increase in pressure;
2. Brain damage: injuries (concussions, bruises), brain tumors, stroke, inflammation of the brain (encephalitis). To increase blood pressure you must:

• or structures that directly affect blood pressure are damaged (the vasomotor center in the medulla oblongata or the associated hypothalamic nuclei or reticular formation);
• or extensive brain damage may occur with increased intracranial pressure, when in order to ensure blood supply to this vital organ the body will need to increase blood pressure.

Reflex hypertension is also classified as neurogenic. They can be:

• conditioned reflex, when at first there is a combination of some event with taking a medicine or drink that increases blood pressure (for example, if a person drinks strong coffee before an important meeting). After many repetitions, the pressure begins to rise only at the very thought of a meeting, without drinking coffee;
• unconditioned reflex, when the pressure increases after the cessation of long-term constant impulses from inflamed or pinched nerves to the brain (for example, if a tumor that was pressing on the sciatic or any other nerve was removed).

Endocrine (hormonal) hypertension

These are secondary hypertension, the causes of which are diseases of the endocrine system. They are divided into several types.

Adrenal hypertension

These glands, located above the kidneys, produce a large number of hormones that can affect vascular tone and the strength or frequency of heart contractions. Increased blood pressure can be caused by:

1. Excessive production of adrenaline and norepinephrine, which is typical for a tumor such as pheochromocytoma. Both of these hormones simultaneously increase the strength and frequency of heart contractions and increase vascular tone;
2. A large amount of the hormone aldosterone, which does not release sodium from the body. This element, appearing in the blood in large quantities, “attracts” water from the tissues. Accordingly, the amount of blood increases. This happens with a tumor that produces it - malignant or benign, with non-tumor growth of the tissue that produces aldosterone, as well as with stimulation of the adrenal glands in severe diseases of the heart, kidneys, and liver.
3. Increased production of glucocorticoids (cortisone, cortisol, corticosterone), which increase the number of receptors (that is, special molecules on the cell that act as a “lock” that can be opened with a “key”) for adrenaline and norepinephrine (they will be the necessary “key” for “ castle") in the heart and blood vessels. They also stimulate the liver to produce the hormone angiotensinogen, which plays a key role in the development of hypertension. An increase in the amount of glucocorticoids is called Cushing's syndrome and disease (a disease when the pituitary gland commands the adrenal glands to produce a large amount of hormones, a syndrome when the adrenal glands are affected).

Hyperthyroid hypertension

It is associated with excessive production of the thyroid hormones – thyroxine and triiodothyronine. This leads to an increase in heart rate and the amount of blood ejected by the heart per beat.

The production of thyroid hormones can increase with autoimmune diseases such as Graves' disease and Hashimoto's thyroiditis, with inflammation of the gland (subacute thyroiditis), and some of its tumors.

Excessive release of antidiuretic hormone by the hypothalamus

This hormone is produced in the hypothalamus. Its second name is vasopressin (translated from Latin as “squeezing blood vessels”), and it acts in this way: by binding to receptors on the vessels inside the kidney, it causes them to narrow, resulting in less urine being produced. Accordingly, the volume of liquid in the vessels increases. More blood flows to the heart - it stretches more. This leads to increased blood pressure.

Hypertension can also be caused by an increase in the body's production of active substances that increase vascular tone (these are angiotensins, serotonin, endothelin, cyclic adenosine monophosphate) or a decrease in the amount of active substances that should dilate blood vessels (adenosine, gamma-aminobutyric acid, nitric oxide, some prostaglandins).

The decline of the function of the gonads is often accompanied by a constant increase in blood pressure. The age at which each woman enters menopause is different (it depends on genetic characteristics, living conditions and the state of the body), but German doctors have proven that the age over 38 years is dangerous for the development of arterial hypertension. It is after 38 years that the number of follicles (from which eggs are formed) begins to decrease not by 1-2 every month, but by dozens. A decrease in the number of follicles leads to a decrease in the production of hormones by the ovaries, as a result of which vegetative (sweating, paroxysmal feeling of heat in the upper body) and vascular (redness of the upper half of the body during a hot attack, increased blood pressure) disorders develop.

Hypoxic hypertension

They develop when blood supply to the medulla oblongata, where the vasomotor center is located, is disrupted. This is possible with atherosclerosis or thrombosis of the vessels carrying blood to it, as well as with compression of the vessels due to edema and hernias.

Renal hypertension

As already mentioned, there are 2 types of them:

Vasorenal (or renovascular) hypertension

It is caused by deterioration of the blood supply to the kidneys due to narrowing of the arteries supplying the kidneys. They suffer from the formation of atherosclerotic plaques in them, an increase in the muscle layer in them due to a hereditary disease - fibromuscular dysplasia, aneurysm or thrombosis of these arteries, aneurysm of the renal veins.

The disease is based on activation of the hormonal system, which causes blood vessels to spasm (contract), sodium retention occurs, and fluid in the blood increases, and the sympathetic nervous system is stimulated. The sympathetic nervous system, through its special cells located on the vessels, activates their even greater compression, which leads to an increase in blood pressure.

Renoparenchymal hypertension

It accounts for only 2-5% of hypertension cases. It occurs due to diseases such as:

• glomerulonephritis;
• kidney damage due to diabetes;
• one or more cysts in the kidneys;
• kidney injury;
• kidney tuberculosis;
• kidney tumor.

With any of these diseases, the number of nephrons (the main working units of the kidneys through which blood is filtered) decreases. The body tries to correct the situation by increasing the pressure in the arteries that carry blood to the kidneys (the kidneys are an organ for which blood pressure is very important; if the pressure is low, they stop working).

Drug-induced hypertension

The following drugs can cause increased blood pressure:

• vasoconstrictor drops used for a runny nose;
• tablet contraceptives;
• antidepressants;
• painkillers;
• drugs based on glucocorticoid hormones.

Hemic hypertension

Due to an increase in blood viscosity (for example, in Vaquez disease, when the number of all its cells in the blood increases) or an increase in blood volume, blood pressure may increase.

Hemodynamic hypertension

This is the name for hypertension, which is based on changes in hemodynamics - that is, the movement of blood through the vessels, usually as a result of diseases of large vessels.

The main disease causing hemodynamic hypertension is coarctation of the aorta. This is a congenital narrowing of the aorta in its thoracic (located in the chest cavity) section. As a result, in order to ensure normal blood supply to the vital organs of the thoracic cavity and cranial cavity, blood must reach them through rather narrow vessels that are not designed for such a load. If the blood flow is large and the diameter of the vessels is small, the pressure in them will increase, which is what happens with coarctation of the aorta in the upper half of the body.

The body needs the lower extremities less than the organs of the indicated cavities, so the blood reaches them “not under pressure.” Therefore, such a person’s legs are pale, cold, thin (the muscles are poorly developed due to insufficient nutrition), and the upper half of the body has an “athletic” appearance.

Alcoholic hypertension

How ethyl alcohol-based drinks cause increased blood pressure is still unclear to scientists, but 5-25% of people who regularly drink alcohol have increased blood pressure. There are theories suggesting that ethanol may affect:

• through increased activity of the sympathetic nervous system, which is responsible for vasoconstriction and increased heart rate;
• by increasing the production of glucocorticoid hormones;
• due to the fact that muscle cells more actively absorb calcium from the blood, and are therefore in a state of constant tension.

Mixed hypertension

When any provoking factors are combined (for example, kidney disease and taking painkillers), they add up (summation).

Certain types of hypertension that are not included in the classification

There is no official concept of “juvenile hypertension”. Increased blood pressure in children and adolescents is mainly of a secondary nature. The most common causes of this condition are:

• Congenital malformations of the kidneys.
• Congenital narrowing of the diameter of the renal arteries.
• Pyelonephritis.
• Glomerulonephritis.
• Cyst or polycystic kidney disease.
• Kidney tuberculosis.
• Kidney injury.
• Coarctation of the aorta.
• Essential hypertension.
• Wilms tumor (nephroblastoma) is an extremely malignant tumor that develops from kidney tissue.
• Lesions of either the pituitary gland or the adrenal glands, resulting in a lot of glucocorticoid hormones in the body (Itsenko-Cushing syndrome and disease).
• Thrombosis of arteries or veins of the kidneys
• Narrowing of the diameter (stenosis) of the renal arteries due to a congenital increase in the thickness of the muscular layer of the vessels.
• Congenital disorder of the adrenal cortex, the hypertensive form of this disease.
• Bronchopulmonary dysplasia is damage to the bronchi and lungs by air blown into the ventilator, which was connected to resuscitate the newborn.
• Pheochromocytoma.
• Takayasu's disease is a lesion of the aorta and large branches extending from it due to an attack on the walls of these vessels by one's own immunity.
• Periarteritis nodosa is an inflammation of the walls of small and medium-sized arteries, resulting in the formation of saccular protrusions - aneurysms.

Pulmonary hypertension is not a type of arterial hypertension. This is a life-threatening condition in which the pressure in the pulmonary artery increases. This is the name of the 2 vessels into which the pulmonary trunk (the vessel emanating from the right ventricle of the heart) is divided. The right pulmonary artery carries oxygen-poor blood to the right lung, the left - to the left.

Pulmonary hypertension develops most often in women 30-40 years old and, gradually progressing, is a life-threatening condition, leading to disruption of the right ventricle and premature death. It occurs due to hereditary causes, connective tissue diseases, and heart defects. In some cases, its cause cannot be determined. Manifested by shortness of breath, fainting, fatigue, dry cough. In severe stages, the heart rhythm is disturbed and hemoptysis appears.

Stages, degrees and risk factors

In order to select treatment for people suffering from hypertension, doctors came up with a classification of hypertension according to stages and degrees. We will present it in the form of tables.

Stages of hypertension

The stages of hypertension indicate how much the internal organs have suffered from constantly increased pressure:

	Damage to target organs, which include the heart, blood vessels, kidneys, brain, retina
	The heart, blood vessels, kidneys, eyes, brain are not yet affected
	According to ultrasound of the heart, either the relaxation of the heart is impaired, or the left atrium is enlarged, or the left ventricle is narrower; The kidneys work worse, which is noticeable so far only in urine and blood creatinine tests (the test for kidney waste is called “Blood Creatinine”); vision has not yet become worse, but when examining the fundus of the eye, the ophthalmologist already sees a narrowing of the arterial vessels and an expansion of the venous vessels.
	One of the complications of hypertension has developed: heart failure, manifested either by shortness of breath, or swelling (in the legs or throughout the body), or both of these symptoms; coronary heart disease: either angina pectoris or myocardial infarction; severe damage to the vessels of the retina, due to which vision suffers.

Blood pressure figures at any stage are above 140/90 mmHg. Art.

Treatment of the initial stage of hypertension is mainly aimed at changing lifestyle: including mandatory in the daily routine. Whereas stage 2 and 3 hypertension should already be treated using. Their dose and, accordingly, side effects can be reduced if you help the body restore blood pressure naturally, for example, by giving it additional help.

Degrees of hypertension

The degrees of development of hypertension indicate how high the blood pressure is:

The degree is established without taking blood pressure-lowering drugs. To do this, a person who is forced to take medications that lower blood pressure needs to reduce their dose or completely stop it.

The degree of hypertension is judged by the number of the pressure (“upper” or “lower”), which is greater.

Sometimes grade 4 hypertension is classified. It is treated as isolated systolic hypertension. In any case, we mean a condition when only the upper pressure is increased (above 140 mm Hg), while the lower pressure is within normal limits - up to 90 mm Hg. This condition is most often recorded in older people (associated with decreased elasticity of the aorta). Occurring in young people, isolated systolic hypertension indicates that the thyroid gland needs to be examined: this is how hyperthyroidism “behaves” (an increase in the amount of thyroid hormones produced).

Definition of risk

There is also a classification according to risk groups. The higher the number indicated after the word “risk,” the higher the likelihood that a dangerous disease will develop in the coming years.

There are 4 risk levels:

1. At risk 1 (low), the probability of developing a stroke or heart attack in the next 10 years is less than 15%;
2. With risk 2 (average), this probability in the next 10 years is 15-20%;
3. At risk 3 (high) – 20-30%;
4. At risk 4 (very high) – more than 30%.

Risk factor	Criterion
Arterial hypertension	Systolic pressure >140 mm Hg. and/or diastolic pressure > 90 mm Hg. Art.
	More than 1 cigarette per week
Impaired fat metabolism (according to Lipidogram analysis)	total cholesterol ≥ 5.2 mmol/L or 200 mg/dL; low-density lipoprotein cholesterol (LDL-C) ≥ 3.36 mmol/l or 130 mg/dl; high-density lipoprotein cholesterol (HDL-C) less than 1.03 mmol/l or 40 mg/dl; triglycerides (TG) > 1.7 mmol/l or 150 mg/dl
Increased fasting glucose (based on blood sugar test)	Fasting plasma glucose 5.6-6.9 mmol/l or 100-125 mg/dl Glucose 2 hours after taking 75 grams of glucose – less than 7.8 mmol/L or less than 140 mg/dL
Low glucose tolerance (digestibility)	Fasting plasma glucose less than 7 mmol/L or 126 mg/dL 2 hours after taking 75 grams, glucose is more than 7.8 but less than 11.1 mmol/l (≥140 and<200 мг/дл)
Cardiovascular diseases in close relatives	They are taken into account in men under 55 years of age and women under 65 years of age
Obesity (it is assessed by the Quetelet index, I I=body weight/height in meters* height in meters. Norm I = 18.5-24.99; Pre-obesity I = 25-30)	Obesity of the first degree, where the Quetelet index is 30-35; II degree 35-40; III degree 40 or more.

To assess the risk, target organ damage is also assessed, which is either present or absent. Target organ damage is assessed by:

• hypertrophy (enlargement) of the left ventricle. It is assessed by electrocardiogram (ECG) and cardiac ultrasound;
• kidney damage: for this, the presence of protein is assessed in a general urine test (normally it should not be present), as well as blood creatinine (normally it should be less than 110 µmol/l).

The third criterion that is assessed to determine the risk factor is concomitant diseases:

1. Diabetes mellitus: it is diagnosed if fasting plasma glucose is more than 7 mmol/l (126 mg/dl), and 2 hours after taking 75 g of glucose - more than 11.1 mmol/l (200 mg/dl);
2. Metabolic syndrome. This diagnosis is established if there are at least 3 criteria from the following, and body weight is necessarily considered one of them:

• HDL cholesterol less than 1.03 mmol/l (or less than 40 mg/dl);
• systolic blood pressure more than 130 mm Hg. Art. and/or diastolic pressure greater than or equal to 85 mm Hg. Art.;
• glucose more than 5.6 mmol/l (100 mg/dl);
• waist circumference in men is more than or equal to 94 cm, in women – more than or equal to 80 cm.

Setting the risk level:

Risk level	Diagnosis criteria
	These are men and women under 55 years of age who, apart from high blood pressure, have no other risk factors, no target organ damage, or concomitant diseases
	Men over 55 years old, women over 65 years old. There are 1-2 risk factors (including arterial hypertension). No target organ damage
	3 or more risk factors, target organ damage (left ventricular hypertrophy, kidney or retinal damage), or diabetes mellitus, or ultrasound detected atherosclerotic plaques in any arteries
	Have diabetes, angina or metabolic syndrome. It was one of the following: angina pectoris; suffered a myocardial infarction; suffered a stroke or micro-stroke (when a blood clot temporarily blocked an artery in the brain and then dissolved or was eliminated by the body); heart failure; chronic renal failure; peripheral vascular disease; the retina is damaged; an operation was performed to restore blood circulation to the heart

There is no direct connection between the degree of pressure increase and the risk group, but at a high stage the risk will be high. For example, there may be hypertension Stage 1, degree 2, risk 3(that is, there is no damage to target organs, pressure is 160-179/100-109 mm Hg, but the probability of heart attack/stroke is 20-30%), and this risk can be either 1 or 2. But if stage 2 or 3, then the risk cannot be lower than 2.

Examples and interpretation of diagnoses - what do they mean?

What it is - hypertension stage 2, degree 2, risk 3?:

• blood pressure 160-179/100-109 mmHg. Art.
• there are heart problems, determined by ultrasound of the heart, or there is a disorder of the kidneys (according to tests), or there is a disorder in the fundus, but there is no visual impairment;
• there may be either diabetes mellitus, or atherosclerotic plaques are found in some vessel;
• in 20-30% of cases, either a stroke or a heart attack will develop in the next 10 years.

Stage 3, degree 2, risk 3? Here, in addition to the parameters indicated above, there are also complications of hypertension: angina pectoris, myocardial infarction, chronic heart or renal failure, damage to retinal vessels.

Hypertonic disease 3 degrees 3 stages risk 3- everything is the same as for the previous case, only the blood pressure numbers are more than 180/110 mm Hg. Art.

What is hypertension Stage 2, degree 2, risk 4? Blood pressure 160-179/100-109 mmHg. Art., target organs are affected, there is diabetes mellitus or metabolic syndrome.

It even happens when 1st degree hypertension, when the pressure is 140-159/85-99 mm Hg. Art., already available Stage 3, that is, life-threatening complications developed (angina pectoris, myocardial infarction, heart or kidney failure), which, together with diabetes mellitus or metabolic syndrome, caused risk 4.

This does not depend on how much the blood pressure increases (the degree of hypertension), but on what complications the persistently high blood pressure caused:

Stage 1 hypertension

In this case, there is no damage to target organs, so disability is not given. But the cardiologist gives recommendations to the person, which he must take to the workplace, where it is written that he has certain restrictions:

• Heavy physical and emotional stress is contraindicated;
• You cannot work the night shift;
• work in conditions of intense noise and vibration is prohibited;
• You cannot work at height, especially when a person is servicing electrical networks or electrical units;
• You cannot perform those types of work in which a sudden loss of consciousness can create an emergency situation (for example, public transport drivers, crane operators);
• those types of work in which there is a change in temperature conditions are prohibited (bathhouse attendants, physiotherapists).

Stage 2 hypertension

In this case, target organ damage is implied, which worsens the quality of life. Therefore, at the VTEK (MSEC) - medical labor or health expert commission - he is given disability group III. At the same time, the restrictions that are indicated for stage 1 of hypertension remain the same. A working day for such a person can be no more than 7 hours.

To obtain disability you need:

• submit an application addressed to the chief physician of the medical institution where MSEC is carried out;
• receive a referral to a commission at the clinic at your place of residence;
• confirm the group annually.

Stage 3 hypertension

Diagnosis of hypertension 3 stages, no matter how high the pressure is - 2 degrees or more, implies damage to the brain, heart, eyes, kidneys (especially if there is a combination with diabetes mellitus or metabolic syndrome, which gives it risk 4), which significantly limits the ability to work. Because of this, a person can receive II or even I group disability.

Let's consider the “relationship” between hypertension and the army, regulated by Decree of the Government of the Russian Federation of July 4, 2013 N 565 “On approval of the Regulations on military medical examination”, Article 43:

Are they recruited into the army with hypertension if the increase in blood pressure is associated with disorders of the autonomic (which controls the internal organs) nervous system: sweating of the hands, variability of pulse and pressure when changing body position)? In this case, a medical examination is carried out under Article 47, on the basis of which either category “B” or “B” is assigned (“B” - fit with minor restrictions).

If, in addition to hypertension, the conscript has other diseases, they will be examined separately.

Is it possible to completely cure hypertension? This is possible if you eliminate those described in detail above. To do this, you need to be thoroughly examined, if one doctor does not help you find the cause, consult with him about which specialist you should go to. Indeed, in some cases, it is possible to remove a tumor or expand the diameter of blood vessels with a stent - and get rid of painful attacks forever and reduce the risk of life-threatening diseases (heart attack, stroke).

Don't forget: a number of causes of hypertension can be eliminated by giving the body additional information. This is called, and helps speed up the removal of damaged and spent cells. In addition, it renews immune reactions and helps to carry out reactions at the tissue level (it will act like a massage at the cellular level, improving the connection of necessary substances with each other). As a result, the body will not need to increase blood pressure.

The phonation procedure can be performed while sitting comfortably on the bed. The devices do not take up much space, are easy to use, and their cost is quite affordable for the general population. Its use is more cost-effective: this way you make a one-time purchase, instead of constantly purchasing medications, and, in addition, the device can treat not only hypertension, but also other diseases, and can be used by all family members). It is also useful to use phonation after eliminating hypertension: the procedure will increase the tone and resources of the body. With help you can achieve general health improvement.

The effectiveness of the devices is confirmed.

For the treatment of stage 1 hypertension, such an effect may be quite sufficient, but when a complication has already developed, or hypertension is accompanied by diabetes mellitus or metabolic syndrome, therapy should be agreed upon with a cardiologist.

Bibliography

1. Guide to Cardiology: Textbook in 3 volumes / Ed. G.I. Storozhakova, A.A. Gorbachenkova. – 2008 - T. 1. - 672 p.
2. Internal diseases in 2 volumes: textbook / Ed. ON THE. Mukhina, V.S. Moiseeva, A.I. Martynov - 2010 - 1264 p.
3. Aleksandrov A.A., Kislyak O.A., Leontyeva I.V. and others. Diagnosis, treatment and prevention of arterial hypertension in children and adolescents. – K., 2008 – 37 p.
4. Tkachenko B.I. Normal human physiology. – M, 2005
5. . Military Medical Academy named after. CM. Kirov, St. Petersburg. 1998
6. P. A. Novoselsky, V. V. Chepenko (Vladimir Regional Hospital).
7. P. A. Novoselsky (Vladimir Regional Hospital).
8. . Military Medical Academy named after. CM. Kirova, St. Petersburg, 2003
9. . State Medical Academy named after. I.I. Mechnikov, St. Petersburg. 2003
10. Dissertation of candidate of medical sciences Svizhenko A.A., Moscow, 2009.
11. Order of the Ministry of Labor and Social Protection of the Russian Federation dated December 17, 2015 No. 1024n.
12. Decree of the Government of the Russian Federation dated July 4, 2013 No. 565 “On approval of the Regulations on military medical examination.”
13. Wikipedia.

You can ask questions (below) on the topic of the article and we will try to answer them competently!

The material was prepared by Villevalde S.V., Kotovskaya Yu.V., Orlova Y.A.

The central event of the 28th European Congress on Arterial Hypertension and Cardiovascular Prevention was the first presentation of a new version of the joint recommendations for the management of arterial hypertension (HTN) of the European Society of Cardiology and the European Society of Hypertension. The text of the document will be published on August 25, 2018, simultaneously with the official presentation at the Congress of the European Society of Cardiology, which will take place on August 25-29, 2018 in Munich. The publication of the full text of the document will undoubtedly give rise to analysis and detailed comparison with the recommendations of American societies, presented in November 2017, which radically changed the diagnostic criteria for hypertension and target blood pressure (BP) levels. The purpose of this material is to provide information on the key provisions of the updated European recommendations.

The full recording of the plenary meeting, where the recommendations were presented, can be viewed on the website of the European Society for AH www.eshonline.org/esh-annual-meeting.

Classification of blood pressure levels and determination of hypertension

Experts from the European Society of Hypertension have retained the classification of blood pressure levels and the definition of hypertension and recommend classifying blood pressure as optimal, normal, high normal and identifying grades 1, 2 and 3 of hypertension (class of recommendations I, level of evidence C) (Table 1).

Table 1. Classification of clinical blood pressure

The criterion for hypertension according to clinical blood pressure measurements remained a level of 140 mm Hg. and higher for systolic (SBP) and 90 mm Hg. and higher - for diastolic (DBP). For home blood pressure measurements, SBP 135 mmHg was retained as a criterion for hypertension. and above and/or DBP 85 mm Hg. and higher. According to daily blood pressure monitoring, the diagnostic cut-off points for average daily blood pressure were, respectively, 130 and 80 mm Hg, daytime - 135 and 85 mm Hg, night - 120 and 70 mm Hg (Table 2) .

Table 2. Diagnostic criteria for hypertension according to clinical and outpatient measurements

Blood pressure measurement

The diagnosis of hypertension continues to rely on clinical BP measurements, with the use of ambulatory BP measurements encouraged and the complementary value of ambulatory blood pressure monitoring (ABPM) and home BP measurements emphasized. For office-based, unattended BP measurement, it is recognized that there is currently insufficient evidence to recommend it for widespread clinical use.

Advantages of ABPM include: detection of white-coat hypertension, stronger prognostic value, assessment of BP levels at night, measurement of BP in the patient's real life, additional ability to identify prognostically significant BP phenotypes, broad information in a single test, including short-term BP variability. Limitations of ABPM include the high cost and limited availability of the study, as well as its possible inconvenience for the patient.

Advantages of home BP measurement include detection of white coat hypertension, cost-effectiveness and widespread availability, measurement of BP in routine settings when the patient is more relaxed than at the doctor's office, patient participation in BP measurement, ability to be repeated over long periods of time, and assessment of variability. "day by day". The disadvantage of the method is the possibility of obtaining measurements only at rest, the likelihood of erroneous measurements and the lack of measurements during sleep.

The following are recommended as indications for performing ambulatory blood pressure measurements (ABPM or home blood pressure): conditions when there is a high probability of white coat hypertension (stage 1 hypertension when clinically measured, a significant increase in clinical blood pressure without target organ damage associated with hypertension), conditions when latent hypertension is highly likely (high normal BP by clinical measurement, normal clinical BP in a patient with end-organ damage or high overall cardiovascular risk), postural and postprandial hypotension in patients not receiving and receiving antihypertensive therapy, assessment of resistant hypertension , assessment of blood pressure control, especially in high-risk patients, excessive blood pressure response to exercise, significant variability in clinical blood pressure, assessment of symptoms indicating hypotension during antihypertensive therapy. A specific indication for performing ABPM is the assessment of nocturnal BP and nocturnal decrease in BP (for example, if nocturnal hypertension is suspected in patients with sleep apnea, chronic kidney disease (CKD), diabetes mellitus (DM), endocrine hypertension, autonomic dysfunction).

Screening and diagnosis of hypertension

To diagnose hypertension, clinical blood pressure measurement is recommended as a first step. When hypertension is detected, it is recommended to either measure blood pressure at follow-up visits (except in cases of grade 3 blood pressure elevation, especially in high-risk patients), or perform ambulatory blood pressure measurement (ABPM or self-monitoring of blood pressure (SBP)). At each visit, 3 measurements should be taken with an interval of 1-2 minutes, an additional measurement should be performed if the difference between the first two measurements is more than 10 mmHg. The patient's blood pressure level is taken as the average of the last two measurements (IC). Ambulatory BP measurement is recommended in a number of clinical situations, such as identifying white-coat hypertension or latent hypertension, quantifying the effectiveness of treatment, and identifying adverse events (symtometic hypotension) (IA).

If white coat hypertension or occult hypertension is detected, lifestyle interventions to reduce cardiovascular risk are recommended, as well as regular monitoring using ambulatory BP measurement (IC). In patients with white coat hypertension, drug treatment of hypertension may be considered in the presence of hypertension-related target organ damage or high/very high cardiovascular risk (IIbC), but routine use of BP-lowering medications is not indicated (IIIC) .

In patients with latent hypertension, drug antihypertensive therapy should be considered to normalize ambulatory blood pressure (IIaC), and in patients receiving treatment with uncontrolled ambulatory blood pressure, intensification of antihypertensive therapy due to the high risk of cardiovascular complications (IIaC).

Regarding blood pressure measurement, the question of the optimal method for measuring blood pressure in patients with atrial fibrillation remains unresolved.

Figure 1. Algorithm for screening and diagnosis of hypertension.

Classification of hypertension and stratification by risk of developing cardiovascular complications

The Recommendations retain the approach to determining the overall cardiovascular risk using SCORE, taking into account the fact that in patients with hypertension, this risk increases significantly in the presence of target organ damage associated with hypertension (especially left ventricular hypertrophy, CKD). Among the factors influencing the cardiovascular prognosis in patients with hypertension, the level of uric acid was added (more precisely, returned), early menopause, psychosocial and economic factors, and a resting heart rate of 80 beats/min or more were added. Asymptomatic target organ damage associated with hypertension includes moderate CKD with glomerular filtration rate (GFR)<60 мл/мин/1,73м 2 , и тяжелая ХБП с СКФ <30 мл/мин/1,73 м 2 (расчет по формуле CKD-EPI), а также выраженная ретинопатия с геморрагиями или экссудатами, отеком соска зрительного нерва. Бессимптомное поражение почек также определяется по наличию микроальбуминурии или повышенному отношению альбумин/креатинин в моче.

The list of established diseases of the cardiovascular system is supplemented by the presence of atherosclerotic plaques in imaging studies and atrial fibrillation.

An approach has been introduced to classify hypertension according to the stages of the disease (hypertension), taking into account the level of blood pressure, the presence of risk factors affecting the prognosis, target organ damage associated with hypertension, and comorbid conditions (Table 3).

The classification covers the range of blood pressure from high normal to grade 3 hypertension.

There are 3 stages of hypertension (hypertension). The stage of hypertension does not depend on the level of blood pressure, but is determined by the presence and severity of target organ damage.

Stage 1 (uncomplicated) - there may be other risk factors, but there is no end-organ damage. At this stage, patients with grade 3 hypertension are classified as high risk, regardless of the number of risk factors, as well as patients with grade 2 hypertension with 3 or more risk factors. The moderate-high risk category includes patients with stage 2 hypertension and 1-2 risk factors, as well as stage 1 hypertension with 3 or more risk factors. The moderate risk category includes patients with grade 1 hypertension and 1-2 risk factors, grade 2 hypertension without risk factors. Patients with high normal blood pressure and 3 or more risk factors correspond to low-moderate risk. The remaining patients were classified as low risk.

Stage 2 (asymptomatic) implies the presence of asymptomatic target organ damage associated with hypertension; CKD stage 3; DM without target organ damage and assumes the absence of symptomatic cardiovascular diseases. The state of target organs corresponding to stage 2, with high normal blood pressure, places the patient in the moderate-high risk group, with increased blood pressure of 1-2 degrees - in the high-risk category, 3 degrees - in the high-very high risk category.

Stage 3 (complicated) is determined by the presence of symptomatic cardiovascular diseases, CKD stage 4 or higher, and diabetes with target organ damage. This stage, regardless of blood pressure level, places the patient in the very high risk category.

Assessment of organ damage is recommended not only to determine risk, but also for monitoring during treatment. Changes in electro- and echocardiographic signs of left ventricular hypertrophy and GFR during treatment have a high prognostic value; moderate - dynamics of albuminuria and ankle-brachial index. Changes in the thickness of the intima-medial layer of the carotid arteries have no prognostic significance. There is insufficient data to conclude on the prognostic value of pulse wave velocity dynamics. There is no data on the significance of the dynamics of signs of left ventricular hypertrophy according to magnetic resonance imaging.

The role of statins has been emphasized to reduce cardiovascular risk, including greater risk reduction while achieving BP control. Antiplatelet therapy is indicated for secondary prevention and is not recommended for primary prevention in patients without cardiovascular disease.

Table 3. Classification of hypertension by stages of the disease, taking into account the level of blood pressure, the presence of risk factors affecting the prognosis, target organ damage associated with hypertension and comorbid conditions

Stage of hypertension	Other risk factors, POM and diseases	High normal blood pressure	AH 1st degree	AH 2 degrees	AH 3 degrees
Stage 1 (uncomplicated)	There are no other FRs	Low risk	Low risk	Moderate risk	High risk
		Low risk	Moderate risk	Moderate - high risk	High risk
	3 or more RF	Low-moderate risk	Moderate - high risk	High risk	High risk
Stage 2 (asymptomatic)	AH-POM, stage 3 CKD or diabetes without POM	Moderate - high risk	High risk	High risk	High-very high risk
Stage 3 (complicated)	Symptomatic CVD, CKD ≥ stage 4 or	Very high risk	Very high risk	Very high risk	Very high risk

POM - target organ damage, AG-POM - target organ damage associated with hypertension, RF - risk factors, CVD - cardiovascular diseases, DM - diabetes mellitus, CKD - ​​chronic kidney disease

Initiation of antihypertensive therapy

Lifestyle changes are recommended for all patients with hypertension or high normal blood pressure. The time of initiation of drug therapy (simultaneously with non-drug interventions or delayed) is determined by the level of clinical blood pressure, the level of cardiovascular risk, the presence of target organ damage or cardiovascular diseases (Fig. 2). As before, immediate initiation of drug antihypertensive therapy is recommended for all patients with grade 2 and 3 hypertension, regardless of the level of cardiovascular risk (IA), and the target blood pressure level should be achieved no later than after 3 months.

In patients with stage 1 hypertension, recommendations for lifestyle changes should begin with subsequent assessment of their effectiveness in normalizing blood pressure (IIB). In patients with grade 1 hypertension at high/very high cardiovascular risk, with cardiovascular disease, renal disease, or evidence of end-organ damage, drug antihypertensive therapy is recommended concomitantly with the initiation of lifestyle interventions (IA). A more decisive (IA) approach compared to the 2013 Guidelines (IIaB) is the approach to initiating drug antihypertensive therapy in patients with stage 1 hypertension with low-moderate cardiovascular risk without heart or kidney disease, without signs of target organ damage in the absence of normalization BP after 3-6 months of initial lifestyle change strategy.

A new provision of the 2018 Recommendations is the possibility of drug therapy in patients with high normal blood pressure (130-139/85-89 mm Hg) in the presence of a very high cardiovascular risk due to the presence of cardiovascular diseases, especially coronary heart disease (CHD). ) (IIbA). According to the 2013 Guidelines, drug antihypertensive therapy was not indicated in patients with high normal blood pressure (IIIA).

One of the new conceptual approaches in the 2018 version of the European recommendations is a less conservative tactic for blood pressure control in the elderly. Experts suggest lower cut-off blood pressure levels for initiating antihypertensive therapy and lower target blood pressure levels in elderly patients, emphasizing the importance of assessing the patient's biological rather than chronological age, taking into account frailty, ability to self-care, and tolerability of therapy.

In fit older patients (even those aged >80 years), antihypertensive therapy and lifestyle changes are recommended when SBP is ≥160 mmHg. (IA). The grade of recommendation and level of evidence was increased (to IA versus IIbC in 2013) for antihypertensive drug therapy and lifestyle changes in “robust” elderly patients (> 65 years, but not older than 80 years) with SBP levels in the range of 140-159 mm Hg, provided the treatment is well tolerated. If therapy is well tolerated, drug therapy may also be considered in frail elderly patients (IIbB).

It should be borne in mind that the patient’s achievement of a certain age (even 80 years or more) is not a reason for not prescribing or discontinuing antihypertensive therapy (IIIA), provided it is well tolerated.

Figure 2. Initiation of lifestyle changes and drug antihypertensive therapy at different clinical BP levels.

Notes: CVD – cardiovascular diseases, IHD – coronary heart disease, AH-POM – target organ damage associated with AH

Target blood pressure levels

Presenting their attitude to the results of the SPRINT study, which were taken into account in the United States when formulating new criteria for the diagnosis of hypertension and target blood pressure levels, European experts point out that office measurement of blood pressure without the presence of medical personnel has not previously been used in any of the randomized clinical trials, which served as an evidence base for making decisions on the treatment of hypertension. When measuring blood pressure without the presence of medical personnel, there is no white coat effect, and compared with conventional measurement, the SBP level may be lower by 5-15 mmHg. It is hypothesized that SBP levels in the SPRINT study may correspond to routinely measured SBP levels of 130–140 and 140–150 mmHg. in groups of more and less intensive antihypertensive therapy.

Experts acknowledge that there is strong evidence of benefit from lowering SBP below 140 and even 130 mmHg. Data from a large meta-analysis of randomized clinical trials are presented (Ettehad D, et al. Lancet. 2016;387(10022):957-967), which showed a significant reduction in the risk of developing major hypertension-associated cardiovascular complications with a decrease in SBP for every 10 mm Hg at the initial level 130-139 mmHg. (that is, when the SBP level is less than 130 mm Hg during treatment): the risk of coronary heart disease by 12%, stroke - by 27%, heart failure - by 25%, major cardiovascular events - by 13%, death from any reasons – by 11%. Additionally, another meta-analysis of randomized trials (Thomopoulos C, et al, J Hypertens. 2016;34(4):613-22) also demonstrated a reduction in the risk of major cardiovascular outcomes when achieving SBP less than 130 or DBP less 80 mmHg compared with a less intense decrease in blood pressure (mean blood pressure levels were 122.1/72.5 and 135.0/75.6 mmHg).

However, European experts also provide arguments in support of a conservative approach to target blood pressure levels:

• the incremental benefit of lowering blood pressure decreases as target blood pressure levels decrease;
• Achieving lower BP levels while on antihypertensive therapy is associated with a higher incidence of serious adverse events and discontinuation of therapy;
• Currently, less than 50% of patients receiving antihypertensive therapy achieve target SBP levels<140 мм рт.ст.;
• The evidence for the benefit of lower BP targets is less convincing in several important subpopulations of patients with hypertension: the elderly, those with diabetes, CKD, and CAD.

As a result, the 2018 European recommendations indicate achieving a target blood pressure level of less than 140/90 mmHg as the primary goal. in all patients (IA). If therapy is well tolerated, it is recommended to reduce blood pressure to 130/80 mmHg. or lower in most patients (IA). A target DBP level should be considered below 80 mmHg. in all patients with hypertension, regardless of risk level or comorbid conditions (IIaB).

However, the same blood pressure level cannot be applied to all patients with hypertension. Differences in target SBP levels are determined by patient age and comorbid conditions. Lower SBP targets of 130 mmHg are proposed. or lower - for patients with diabetes (subject to careful monitoring of adverse events) and coronary artery disease (Table 4). In patients with a history of stroke, consider a target SBP of 120 (<130) мм рт.ст. Пациентам с АГ 65 лет и старше или имеющим ХБП рекомендуется достижение целевого уровня САД 130 (<140) мм рт.ст.

Table 4. Target SBP levels in selected subpopulations of patients with hypertension

Notes: DM – diabetes mellitus, IHD – coronary heart disease, CKD – chronic kidney disease, TIA – transient ischemic attack; *- careful monitoring of adverse events; **- if postponed.

A summary of the 2018 Recommendations for target ranges for office BP is presented in Table 5. A new provision that is important for real clinical practice is the designation of the level below which BP should not be reduced: for all patients it is 120 and 70 mm Hg.

Table 5. Clinical BP target ranges

Age, years	Target ranges for office SBP, mmHg.
					Stroke/
	Goal to<130 or lower if tolerated Not less<120	Goal to<130 or lower if tolerated Not less<120	Goal to<140 до 130 if tolerated	Goal to<130 or lower if tolerated Not less<120	Goal to<130 or lower if tolerated Not less<120
	Goal to<140 до 130 if tolerated	Goal to<140 до 130 if tolerated	Goal to<140 до 130 if tolerated	Goal to<140 до 130 if tolerated	Goal to<140 до 130 if tolerated
	Goal to<140 до 130 if tolerated	Goal to<140 до 130 if tolerated	Goal to<140 до 130 if tolerated	Goal to<140 до 130 if tolerated	Goal to<140 до 130 if tolerated
Target range of clinical DBP,

Notes: DM – diabetes mellitus, IHD – coronary heart disease, CKD – chronic kidney disease, TIA – transient ischemic attack.

When discussing ambulatory BP targets (ABPM or ABPM), it should be kept in mind that no randomized clinical trials with hard endpoints have used ABPM or ABPM as criteria for changing antihypertensive therapy. Data on target levels of ambulatory blood pressure are obtained only from extrapolation from observational studies. In addition, the differences between office and ambulatory BP levels decrease as office BP levels decrease. Thus, convergence of 24-hour and office blood pressure is observed at a level of 115-120/70 mmHg. We can assume that the target level of office SBP is 130 mm Hg. approximately corresponds to a 24-hour SBP level of 125 mm Hg. with ABPM and SBP level<130 мм рт.ст. при СКАД.

Along with the optimal target levels of ambulatory blood pressure (ABPM and SBP), questions remain open about the target blood pressure levels in young patients with hypertension and low cardiovascular risk, the target level of DBP.

Lifestyle changes

Treatment of hypertension includes lifestyle changes and drug therapy. Many patients will require drug therapy, but lifestyle changes are important. They can prevent or delay the development of hypertension and reduce cardiovascular risk, delay or eliminate the need for drug therapy in patients with stage 1 hypertension, and enhance the effects of antihypertensive therapy. However, lifestyle changes should never be a reason to delay drug therapy in patients at high cardiovascular risk. The main disadvantage of non-pharmacological interventions is low patient compliance and its decline over time.

Recommended lifestyle changes with a proven lowering effect on blood pressure include: limiting salt, no more than moderate alcohol consumption, high consumption of vegetables and fruits, losing and maintaining body weight, and regular exercise. In addition, a strong recommendation to quit smoking is mandatory. Tobacco smoking has an acute pressor effect that may increase ambulatory daytime blood pressure. Smoking cessation, in addition to its effect on blood pressure, is also important for reducing cardiovascular risk and preventing cancer.

In the previous version of the guidelines, the levels of evidence for lifestyle interventions were stratified by effects on BP and other cardiovascular risk factors and on hard endpoints (cardiovascular outcomes). In the 2018 Guidelines, experts indicated a combined level of evidence. The following lifestyle changes are recommended for patients with hypertension:

• Limit salt intake to 5 g per day (IA). A more stringent position compared to the 2013 version, where a limit to 5-6 g per day was recommended;
• Limit alcohol consumption to 14 units per week for men, 7 units per week for women (1 unit is 125 ml wine or 250 ml beer) (IA). In the 2013 version, alcohol consumption was calculated in grams of ethanol per day;
• Heavy drinking of alcohol should be avoided (IIIA). New position;
• Increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil); consumption of low-fat dairy products; low red meat intake (IA). Experts particularly emphasized the need to increase olive oil consumption;
• Control body weight, avoid obesity (body mass index (BMI) >30 kg/m2 or waist circumference more than 102 cm in men and more than 88 cm in women), maintain a healthy BMI (20-25 kg/m2) and waist circumference (less than 94 cm in men and less than 80 cm in women) to reduce blood pressure and cardiovascular risk (IA);
• Regular aerobic physical activity (at least 30 minutes of moderate dynamic physical activity for 5-7 days a week) (IA);
• Smoking cessation, support and assistance measures, referral of patients to smoking cessation (IB) programs.

Questions remain about the optimal level of salt intake to reduce cardiovascular risk and risk of death, and the effects of other non-pharmacological interventions on cardiovascular outcomes.

Strategy for drug treatment of hypertension

The new Recommendations retain 5 classes of drugs as basic antihypertensive therapy: ACE inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta blockers (BBs), calcium antagonists (CAs), diuretics (thiazide and tazide-like (TD), such as chlorthalidone or indapamide) (IA). At the same time, some changes in the position of the BB are indicated. They can be prescribed as antihypertensive drugs in the presence of specific clinical situations, such as heart failure, angina pectoris, previous myocardial infarction, the need for rhythm control, pregnancy or pregnancy planning. Bradycardia (heart rate less than 60 beats/min) is included as absolute contraindications to BBs and chronic obstructive pulmonary disease is excluded as a relative contraindication to their use (Table 6).

Table 6. Absolute and relative contraindications to the prescription of main antihypertensive drugs.

Drug class	Absolute contraindications	Relative contraindications
Diuretics		Metabolic syndrome Impaired glucose tolerance Pregnancy Hypercalcemia Hypokalemia
Beta blockers	Bronchial asthma Atrioventricular block 2-3 degrees Bradycardia (heart rate<60 ударов в минуту)*	Metabolic syndrome Impaired glucose tolerance Athletes and physically active patients
Dihydropyridine AAs		Tachyarrhythmias Heart failure (CHF with low LVEF, FC II-III) Initial severe swelling of the lower extremities*
Non-dihydropyridine AA (verapamil, diltiazem)	Sinoatrial and atrioventricular blockade of high grades Severe left ventricular dysfunction (LVEF<40%) Bradycardia (heart rate<60 ударов в минуту)*
	Pregnancy History of angioedema Hyperkalemia (potassium >5.5 mmol/l)
	Pregnancy Hyperkalemia (potassium >5.5 mmol/l) 2-sided renal artery stenosis	Women of childbearing age without reliable contraception*

Notes: LVEF – left ventricular ejection fraction, FC – functional class. * – Changes compared to 2013 recommendations are highlighted in bold.

Experts placed special emphasis on starting therapy with 2 drugs for most patients. The main argument for using combination therapy as an initial strategy is the well-founded concern that by prescribing one drug with the prospect of further dose titration or adding a second drug at subsequent visits, most patients will remain on insufficiently effective monotherapy for an extended period of time.

Monotherapy is considered acceptable as a starting therapy for low-risk patients with stage 1 hypertension (if SBP<150 мм рт.ст.) и очень пожилых пациентов (старше 80 лет), а также у пациенто со старческой астенией, независимо от хронологического возраста (табл. 7).

Patient adherence to treatment is considered one of the most important components of successful blood pressure control. In this regard, combinations of two or more antihypertensive drugs combined in one tablet have advantages over free combinations. The new 2018 Recommendations increased the class and level of evidence for initiation of therapy from a double fixed combination (the “single tablet” strategy) to IV.

The recommended combinations remain combinations of RAAS blockers (ACEIs or ARBs) with CB or TD, preferably in a single tablet (IA). It is noted that other drugs from the 5 main classes can be used in combinations. If dual therapy is ineffective, a third antihypertensive drug should be prescribed. The triple combination of RAAS blockers (ACE inhibitors or ARBs), AK with TD (IA) retains its priorities as a base one. If target blood pressure levels are not achieved with triple therapy, the addition of small doses of spironolactone is recommended. If it is intolerant, eplerenone, or amiloride, or high doses of TD, or loop diuretics can be used. Beta or alpha blockers may also be added to therapy.

Table 7. Algorithm for drug treatment of uncomplicated hypertension (can also be used for patients with target organ damage, cerebovascular disease, diabetes mellitus and peripheral atherosclerosis)

Stages of therapy	Drugs	Notes
	ACEI or ARB AK or TD	Monotherapy for low-risk patients with SBP<150 мм рт.ст., очень пожилых (>80 years old) and patients with senile asthenia
	ACEI or ARB
Triple combination (preferably in 1 tablet) + spironolactone, if it is intolerant, another drug	ACEI or ARB AK + TD + spironolactone (25-50 mg once a day) or another diuretic, alpha or beta blocker	This situation is regarded as resistant hypertension and requires referral to a specialized center for additional examination.

The Recommendations present approaches to the management of hypertensive patients with comorbid conditions. When hypertension is combined with CKD, as in previous Recommendations, it is indicated that it is mandatory to replace TD with loop diuretics when GFR decreases to less than 30 ml/min/1.73 m2 (Table 8), as well as the impossibility of prescribing two RAAS blockers (IIIA) . The issue of “individualization” of therapy is discussed depending on treatment tolerability, kidney function indicators and electrolytes (IIaC).

Table 8. Algorithm for drug treatment of hypertension in combination with CKD

Stages of therapy	Drugs	Notes
CKD (GFR<60 мл/мин/1,73 м 2 с наличием или отсутствием протеинурии)
Initial therapy Double combination (preferably in 1 tablet)	ACEI or ARB AK or TD/TPD (or loop diuretic*)	The use of a beta-blocker can be considered at any stage of therapy in specific clinical situations, such as heart failure, angina pectoris, previous myocardial infarction, atrial fibrillation, pregnancy or pregnancy planning.
Triple combination (preferably in 1 tablet)	ACEI or ARB (or loop diuretic*)
Triple combination (preferably 1 tablet) + spironolactone** or other drug	ACEI or ARB+AC+ TD + spironolactone** (25-50 mg once daily) or other diuretic, alpha or beta blocker
*- if eGFR<30 мл/мин/1,73м 2 ** - caution: administration of spironolactone is associated with a high risk of hyperkalemia, especially if baseline eGFR<45 мл/мин/1,73 м 2 , а калий ≥4,5 ммоль/л

The algorithm for drug treatment of hypertension in combination with coronary heart disease (CHD) has more significant features (Table 9). In patients with a history of myocardial infarction, it is recommended to include BB and RAAS blockers (IA) in the therapy; in the presence of angina, preference should be given to BB and/or AK (IA).

Table 9. Algorithm for drug treatment of hypertension in combination with coronary artery disease.

Stages of therapy	Drugs	Notes
Initial therapy Double combination (preferably in 1 tablet)	ACEI or ARB BB or AK AK + TD or BB	Monotherapy for patients with stage 1 hypertension, the very elderly (>80 years) and “frail”. Consider initiating therapy if SBP ≥130 mmHg.
Triple combination (preferably in 1 tablet)	Triple combination of the above drugs
Triple combination (preferably 1 tablet) + spironolactone or other drug	Add spironolactone (25-50 mg once daily) or another diuretic, alpha or beta blocker to the triple combination	This situation is regarded as resistant hypertension and requires referral to a specialized center for additional examination.

An obvious choice of drugs is proposed for patients with chronic heart failure (CHF). In patients with CHF and low EF, the use of ACE inhibitors or ARBs and BBs, as well as, if necessary, diuretics and/or mineralocorticoid receptor antagonists (IA) is recommended. If the target blood pressure is not achieved, the possibility of adding dihydropyridine AKs (IIbC) is considered. Since no single group of drugs has proven superior in patients with preserved EF, all 5 classes of antihypertensive agents (IC) can be used. In patients with left ventricular hypertrophy, it is recommended to prescribe RAAS blockers in combination with AK and TD (I A).

Long-term follow-up of patients with hypertension

A decrease in blood pressure develops within 1-2 weeks from the start of therapy and continues over the next 2 months. During this period, it is important to schedule a first visit to assess the effectiveness of treatment and monitor the development of side effects of the drugs. Subsequent monitoring of blood pressure should be carried out at the 3rd and 6th months of therapy. The dynamics of risk factors and the severity of target organ damage should be assessed after 2 years.

Particular attention was paid to the observation of patients with high normal blood pressure and white coat hypertension, for whom it was decided not to prescribe drug therapy. They should be examined annually to assess blood pressure, changes in risk factors and lifestyle changes.

At all stages of patient monitoring, it is necessary to evaluate adherence to treatment as a key reason for poor blood pressure control. To this end, it is proposed to carry out activities at several levels:

• Clinician level (providing information about the risks of hypertension and the benefits of therapy; prescribing optimal therapy, including lifestyle changes and combination drug therapy combined into one pill whenever possible; increasing patient empowerment and feedback ; interaction with pharmacists and nurses).
• Patient level (independent and remote monitoring of blood pressure, use of reminders and motivational strategies, participation in educational programs, self-adjustment of therapy in accordance with simple algorithms for patients; social support).
• Level of therapy (simplification of therapeutic regimens, “one pill” strategy, use of calendar packs).
• Level of the health care system (development of monitoring systems; financial support for interaction with nurses and pharmacists; reimbursement of patients for fixed combinations; development of a national information base for drug prescriptions accessible to doctors and pharmacists; increasing the availability of drugs).

• Expanding opportunities for the use of 24-hour blood pressure monitoring and blood pressure self-monitoring in the diagnosis of hypertension
• Introduction of new target blood pressure ranges depending on age and comorbidities.
• Reducing conservatism in the management of elderly and senile patients. To select tactics for managing elderly patients, it is proposed to focus not on chronological, but on biological age, which involves assessing the severity of senile asthenia, the ability to self-care and tolerability of therapy.
• Introduction of a “one pill” strategy for the treatment of hypertension. Preference is given to prescribing fixed combinations of 2, and, if necessary, 3 drugs. Starting therapy with 2 drugs in 1 tablet is recommended for most patients.
• Simplification of therapeutic algorithms. In most patients, preference should be given to combinations of a RAAS blocker (ACEI or ARB) with a CCB and/or TD. BBs should be prescribed only in specific clinical situations.
• Increased attention to assessing patient adherence to treatment as the main reason for insufficient blood pressure control.
• Increasing the role of nurses and pharmacists in the education, monitoring and support of patients with hypertension as an important component of the overall blood pressure control strategy.

Recording of the plenary session of the 28th

European Congress on Arterial Hypertension and Cardiovascular

Villevalde Svetlana Vadimovna – Doctor of Medical Sciences, Professor, Head of the Department of Cardiology, National Medical Research Center named after. V.A. Almazov" of the Russian Ministry of Health.

Yulia Viktorovna Kotovskaya - Doctor of Medical Sciences, Professor, Deputy Director for Scientific Work of the OSP Russian Gerontological Research and Clinical Center of the Federal State Budgetary Educational Institution of Higher Education Russian National Research Medical University named after. N.I. Pirogov Ministry of Health of Russia

Orlova Yana Arturovna – Doctor of Medical Sciences, Professor of the Department of Multidisciplinary Clinical Training, Faculty of Fundamental Medicine, Moscow State University named after M.V. Lomonosov, Head. Department of Age-Associated Diseases of the Medical Research and Educational Center of Moscow State University named after M.V. Lomonosov.