^ Main clinical characteristics of hypertensive crisis

Blood pressure: diastolic usually above 140 mmHg.

Changes in the fundus: hemorrhages, exudates, swelling of the optic nerve papilla.

Neurological changes: dizziness, headaches, confusion, drowsiness, stupor, nausea, vomiting, loss of vision, focal symptoms (neurological deficit), loss of consciousness, coma.

Depending on the predominance of certain clinical symptoms, types of hypertensive crises are sometimes distinguished: neurovegetative, edematous, convulsive.

Formulation of diagnoses for certain diseases of the cardiovascular system

Main disease: Hypertensive disease of the 2nd degree, stage II, risk 3. Atherosclerosis of the aorta, carotid arteries.

Coded I ^ 10 as essential (primary) arterial hypertension.

Main disease: Hypertensive disease of the 2nd degree, stage III, risk 4. Atherosclerosis of the aorta, coronary arteries. Complications: CHF stage IIA (FC II). Concomitant disease: Sequelae of Ischemic Stroke (March 2001)

Coded I 11.0 as hypertension with a primary lesion of the heart with congestive heart failure.

Main disease: Hypertensive disease of the 2nd degree, stage III, risk 4. Atherosclerosis of the aorta, coronary arteries. ischemic heart disease. Angina pectoris, FC P. Postinfarction cardiosclerosis. Complications: Aneurysm of the left ventricle. CHF stage IIA (FC II). Right-sided hydrothorax. Nephrosclerosis. Chronic renal failure. Concomitant disease: Chronic gastritis.

Coded I 13.2 as hypertension with a primary lesion of the heart and kidneys with congestive heart failure and renal failure. This diagnosis is correct if the cause of hospitalization of the patient was hypertension. If hypertension is an underlying disease, one or another form of coronary heart disease is coded (see below).

In the case of a hypertensive crisis, codes I11-I13 are used (depending on the presence of involvement of the heart and kidneys). The code ON can only be if signs of damage to the heart or kidneys are not detected.

By virtue of the foregoing, wrong diagnosis:

^ Underlying disease: Hypertension, stage III. Concomitant disease: Varicose veins of the lower extremities.

The main mistake is v the fact that the doctor indicated the third stage of hypertension, which is established in the presence of one or more associated diseases, but they are not indicated in the diagnosis. In this case the code can be used ON, which is most likely not true. 38

^ Formulation of diagnoses for certain diseases of the cardiovascular system

Secondary (symptomatic) arterial hypertension

I15 Secondary hypertension

I15.0 Renovascular hypertension

I15.1 Hypertension secondary to others

kidney damage

I15.2 Hypertension secondary to endo

critical disorders

I15.8 Other secondary hypertension

I15.9 Secondary hypertension, unspecified

If arterial hypertension is secondary, that is, it can be considered as a symptom of a disease, then the clinical diagnosis is formed in accordance with the rules related to this disease. ICD-10 codes I 15 used in the event that arterial hypertension as the leading symptom determines the main costs for the diagnosis and treatment of the patient.

Examples of the formulation of the diagnosis

The patient, who applied in connection with arterial hypertension, had an increase in serum creatinine, proteinuria. He is known to have been suffering from type 1 diabetes for a long time. Here are some formulations of diagnoses that occur in this situation.

^ Underlying disease: Diabetes mellitus type 1, stage of compensation. Complication: diabetic nephropathy. arterial hypertension. Chronic renal failure, stage I

^ Underlying disease: Hypertensive disease of the 3rd degree, stage III. Complications: Nephrosclerosis. Chronic renal failure, stage I. Concomitant disease: Diabetes mellitus type 1, stage of compensation.

^ Underlying disease: Arterial hypertension, stage III, against the background of diabetic nephropathy. Complication: Chronic renal failure, stage I. Concomitant disease: Diabetes mellitus type 1, stage of compensation.

Taking into account the fact that arterial hypertension in the patient is associated with diabetic nephropathy, diabetes mellitus is compensated, and the main medical measures were aimed at correcting high blood pressure, right will be tre-

Formulation of diagnoses for certain diseases of the cardiovascular system

ty variant of the diagnosis 5. The case is coded I 15.2 as hypertension secondary to endocrine disorders, in this case, diabetes mellitus with kidney damage.

The first option is erroneous, since when formulating a clinical diagnosis, the emphasis is not on a specific condition that was the main reason for treatment and examination, but on the etiology of the syndrome, which in this case has a relatively formal meaning. As a result, the code will be included in the statistics EY. The second option, on the contrary, does not take into account the etiology of hypertension at all, and therefore is also incorrect.

^ 2.5. ISCHEMIC HEART DISEASES

The term "ischemic heart disease" is a group concept.

ICD code: I20-I25

I20 Angina pectoris (angina pectoris)

I20.0 Unstable angina

Our Blog

Examples of formulations of the diagnosis of arterial hypertension

- Hypertension stage II. Degree of hypertension 3. Dyslipidemia.

- Left ventricular hypertrophy. Risk 4 (very high).

- Hypertension stage III. Degree of arterial hypertension 2. IHD. Angina pectoris II FC. Risk 4 (very high).

V.S.Gasilin, P.S.Grigoriev, O.N.Mushkin, B.A.Blokhin. Clinical classifications of some internal diseases and examples of the formulation of diagnoses

OCR: Dmitry Rastorguev

Origin: http://ollo.norna.ru

MEDICAL CENTER FOR THE ADMINISTRATION OF THE PRESIDENT OF THE RUSSIAN FEDERATION

SCIENTIFIC CENTER POLYCLINIC No 2

CLINICAL CLASSIFICATIONS OF SOME INTERNAL DISEASES AND EXAMPLES OF DIAGNOSIS FORMULATION

Reviewer: Head of the Department of Therapy, Moscow Medical Stomatological Institute. N. D. Semashko, Dr. med. Sciences. Professor V. S. ZODIONCHENKO.

I. DISEASES OF THE CARDIOVASCULAR SYSTEM

1. Classification of arterial hypertension (AH)

1. According to the level of blood pressure (BP)

1.1. Normal BP - below 140/90 mm rt st

1.2. Borderline blood pressure - 140-159 / 90-94 mm from art. 1.3_Argerial hypertension - 160/95 mm rt. Art. and higher.

2. By etiology.

2.1. Essential or primary hypertension (hypertension - GB).

2.2. Symptomatic arterial hypertension

Renal: acute and chronic glomerulonephritis; chronic pyelonephritis; interstitial nephritis with gout, hypercalcemia; diabetic glomeruloskerosis; polycystic kidney disease; nodular periarteritis and other intrarenal arteritis; systemic lupus erythematosus; scleroderma; amyloid-wrinkled kidney; hypoplasia and congenital defects of the kidney; urolithiasis disease; obstructive uropathy; hydronephrosis; nephroptosis; hypernephroid cancer; plasmacytoma and some other neoplasms; traumatic perirenal hematoma and other kidney injuries.

Renovascular (vasorenal): fibromuscular dysplasia of the renal arteries; atrosclerosis of the renal arteries; nonspecific aortoarteritis; thrombosis and embolism of the renal arteries; compression of the renal arteries from the outside (tumors, adhesions, hematoma scars).

Endocrine: adrenal (primary aldostetonism, adenoma of the adrenal cortex, bilateral hyperplasia of the adrenal cortex, Itsenko-Cushing's disease and syndrome; congenital adrenal hyperplasia, pheochromocytoma); pituitary (acromegaly), thyroid (thyrotoxicosis), parathyroid (hyperparathyroidism), carcinoid syndrome.

Hemodynamic: atherosclerosis and other aortic seals; coarctation of the aorta; aortic valve insufficiency; complete atrioventricular block; arteriovenous fistulas: open ductus arteriosus, congenital and traumatic aneurysms, Paget's disease (osteitis deformans); congestive circulatory failure; erythremia.

Neurogenic: tumors, cysts, brain injuries; chronic ischemia of the brain with narrowing of the carotid and vertebral arteries; encephalitis; bulbar poliomyelitis.

Late toxicosis of pregnant women.

Exogenous: poisoning (lead, thallium, cadmium, etc.); medicinal effects (prednisolone and other glucocorticoids; mineralocorticoids); contraceptives; severe burns, etc.

Classification of essential hypertension (essential hypertension) (401-404)

By stages: I (functional).

II (cardiac hypertrophy, vascular changes). III (resistant to treatment).

With a primary lesion: heart, kidneys, brain, eyes.

Hypertonic disease

Stage I Signs of changes in the cardiovascular system caused by hypertension are usually not yet detected. DD at rest ranges from 95 to 104 mm Hg. Art. SD - within 160-179 mm Hg. Art. average hemodynamic from 110 to 124 mm Hg. Art. The pressure is labile. It changes noticeably throughout the day.

Stage II. It is characterized by a significant increase in the number of complaints of a cardiac and neurogenic nature. DD at rest fluctuates between 105-114 mm Hg. Art.; SD reaches 180-200 mm Hg. Art. average hemodynamic - 125-140 mm Hg. Art. The main distinguishing feature of the transition of the disease to this stage is left ventricular hypertrophy, usually diagnosed by a physical method (ECG, ECHOCG and X-ray); a clear II tone is heard over the aorta. Changes in the arteries of the fundus. Kidneys:

proteinuria.

Stage III. Severe organic lesions of various organs and systems, accompanied by certain functional disorders (circulatory failure of the left ventricular type, hemorrhage in the cortex, cerebellum or brain stem, retina, or hypertensive encephalopathy). Hypertensive retinopathy with significant changes in the fundus and decreased vision. Treatment-resistant hypertension: DD in the range of 115-129 mm Hg. Art. SD - 200-230 mm Hg. Art. and above, the average hemodynamic - 145-190 mm Hg. Art. With the development of severe complications (myocardial infarction, stroke, etc.), blood pressure, especially systolic, usually decreases significantly, and often to a normal level ("headless hypertension").

Examples of the formulation of the diagnosis

1. Hypertension I stage.

2. Hypertension stage II with a primary lesion of the heart.

Note: the classification of arterial hypertension takes into account the recommendations of the WHO expert committee.

2. Classification of neurocirculatory dystonia (NCD) (306)

Clinical types:

1. Hypertensive.

2. Hypotonic.

3. Cardiac.

According to the severity of the flow:

1. Mild degree - pain and tachycardia syndromes are moderately expressed (up to 100 beats per minute), occur only in connection with significant psycho-emotional and physical stress. There are no vascular crises. There is usually no need for drug therapy. Employability is preserved.

2. Medium degree - a heart attack is persistent. Tachycardia occurs spontaneously, reaching 110-120 beats per minute. Vascular crises are possible. Drug therapy is applied. Ability to work is reduced or temporarily lost.

3. Severe degree - pain syndrome is persistent Tachycardia reaches 130-150 beats. in min. Respiratory disturbances are expressed. Frequent vegetative-vascular crises. Often mental depression. Drug therapy is necessary in a hospital setting. Ability to work is sharply reduced and temporarily lost.

Note: vegetative-vascular dystonia (VVD) is characterized by a combination of autonomic disorders of the body and is indicated in a detailed clinical diagnosis after the underlying disease (pathology of internal organs, endocrine glands, nervous system, etc.), which may be an etiological factor in the occurrence of autonomic disorders .

Examples of the formulation of the diagnosis

1. Neurocirculatory dystonia of hypertonic type, of moderate severity.

2. Climax. Vegetative-vascular dystonia with rare sympathetic-adrenal crises.

3. Classification of coronary heart disease (CHD) (410-414,418)

Angina:

1. Angina pectoris:

1.1. First-time angina pectoris.

1.2. Stable exertional angina with an indication of the functional class of the patient from I to IV.

1.3. Angina pectoris progressive.

1.4. Spontaneous angina (vasospastic, special, variant, Prinzmetal).

2. Acute focal myocardial dystrophy.

3. Myocardial infarction:

3.1. Large-focal (transmural) - primary, repeated (date).

3.2. Small-focal - primary, repeated (date).

4. Postinfarction focal cardiosclerosis.

5. Violation of the heart rhythm (indicating the form).

6. Heart failure (indicating the form and stage).

7. Painless form of coronary artery disease.

8. Sudden coronary death.

Note: The classification of coronary heart disease takes into account the recommendations of the WHO expert committee.

Functional class of stable angina depending on the ability to perform physical activity

I class The patient tolerates normal physical activity well. Attacks of stenocardia occur only with high-intensity loads. UM - 600 kgm and above.

P class- angina attacks occur when walking on a flat place at a distance of more than 500 m, when climbing more than 1 floor. The likelihood of an angina attack increases when walking in cold weather, against the wind, with emotional arousal, or in the first hours after waking up. YuM - 450-600 kgm.

SH class severe limitation of normal physical activity. Attacks occur when walking at a normal pace on level ground at a distance of 100-500 m, when climbing to the 1st floor, rare attacks of rest angina may occur. YuM - 300-450 kgm.

IV class- angina pectoris occurs with small physical exertion, when walking on a flat place at a distance of less than 100 m. The occurrence of angina attacks at rest is typical. YuM - 150 kgm or not carried out.

Note: The classification of the functional classes of stable angina pectoris was compiled taking into account the recommendations of the Canadian Heart Association.

Sudden coronary death- death in the presence of witnesses occurred instantly or within 6 hours from the onset of a heart attack.

New onset angina pectoris- duration up to 1 month from the moment of appearance.

stable angina- Duration more than 1 month.

Progressive angina- an increase in the frequency, severity and duration of seizures in response to the usual load for this patient, a decrease in the effectiveness of nitroglycerin; ECG changes may appear.

Spontaneous (special) angina pectoris- attacks occur during mowing, more difficult to respond to nitroglycerin, can be combined with angina pectoris.

Postinfarction cardiosclerosis- is placed no earlier than 2 months after the onset of myocardial infarction.

Heart rhythm disorder(indicating the form, stage).

Heart failure(indicating the form, stage) - is placed after postinfarction cardiosclerosis.

Examples of the formulation of the diagnosis

1. IHD. First-time angina pectoris.

2. IHD. Angina pectoris and (or) rest, FC - IV, diffuse cardiosclerosis, ventricular extrasystole. But.

3. IHD. Vasospastic angina.

4. IHD. Transmural myocardial infarction in the region of the posterior wall of the left ventricle (date), cardiosclerosis, atrial fibrillation, tachysystolic form, HIIA.

5. IHD. Angina pectoris, FC-III, postinfarction cardiosclerosis (date), blockade of the left bundle branch block. NIIB.

4. Classification of myocarditis (422) (according to N. R. Paleev, 1991)

1. Infectious and infectious-toxic.

1.1. Viral (influenza, Coxsackie infection, poliomyelitis, etc.).

1.2. Bacterial (diphtheria, scarlet fever, tuberculosis, typhoid fever).

1.3. Spirochetosis (syphilis, leptospirosis, relapsing fever).

1.4. Rickettsial (typhus, fever 0).

1.6. Fungal (actinomycosis, candidiasis, coccidioidomycosis, aspergillosis).

2. Allergic (immune): idiopathic (Abramov-Fiedler type), medicinal, serum, nutritional, with systemic connective tissue diseases (systemic lupus erythematosus, scleroderma), with bronchial asthma, Lyell's syndrome, Goodpasture's syndrome, burns, transplantation.

3. Toxic-allergic: thyrotoxic, uremic, alcoholic.

Diagnosis example

1. Infectious-toxic post-influenza myocarditis.

5. Classification of myocardial dystrophy (429) (according to N. R. Paleev, 1991)

According to the etiological characteristics.

1. Anemic.

2. Endocrine and dysmetabolic.

3. Toxic.

4. Alcoholic.

5. Overvoltage.

6. Hereditary and family diseases (muscular dystrophy, Frederick's ataxia).

7. Alimentary.

8. With closed chest injuries, exposure to vibration, radiation, etc.).

Examples of the formulation of the diagnosis

1. Thyrotoxic myocardial dystrophy with outcome in cardiosclerosis, atrial fibrillation, Np B stage.

2. Climax. Myocardial dystrophy. Ventricular extrasystole.

3. Alcoholic myocardial dystrophy, atrial fibrillation, Hsh stage.

6. Classification of cardiomyopathies (425) (WHO, 1983)

1. Dilated (stagnant).

2. Hypertrophic.

3. Restrictive (constrictive)

Note: cardiomyopathy should include lesions of the heart muscle that are not inflammatory or sclerotic in nature (not associated with a rheumatic process, myocarditis, coronary artery disease, cor pulmonale, hypertension of the systemic or pulmonary circulation).

Diagnosis example

1. Dilated cardiomyopathy. Atrial fibrillation. NpB.

7. Classification of rhythm and conduction disorders (427)

1. Violations of the function of the sinus node.

1.1. Sinus tachycardia.

1.2. sinus bradycardia.

1.3. sinus arrhythmia.

1.4. Stopping the sinus node.

1.5. Migration of the supraventricular pacemaker.

1.6. Sick sinus syndrome.

2. Ectopic impulses and rhythms.

2.1. Rhythms from the a-y connection.

2.2. Idioventricular rhythm.

2.3. Extrasystole.

2.3.1. Sinus extrasystoles.

2.3.2. Atrial extrasystoles.

2.3.3. Extrasystoles from a-y connection.

2.3.4. Recurrent extrasystoles.

2.3.5. Extrasystoles from the bundle of His (stem).

2.3.6. Supraventricular extrasystoles with aberrant OK8 complex.

2.3.7. Blocked supraventricular extrasystoles.

2.3.8. Ventricular extrasystoles. 2.4. Ectopic tachycardia:

2.4.1. Atrial paroxysmal tachycardia.

2.4.2. Tachycardia from a-y connections with simultaneous excitation of the atria and ventricles or with previous excitation of the ventricles.

2.4.3. Right ventricular or left ventricular paroxysmal tachycardia.

3. Violations of impulse conduction (blockade).

3.1. Sinoatrial blockade (SA blockade).

3.1.1. Incomplete SA blockade with Wenckebach periods (II degree, type I).

3.1.2. Incomplete SA blockade without Wenckebach periods (II degree II type).

3.2. Deceleration of atrial conduction (incomplete atrial block):

3.2.1. Complete interatrial block.

3.3. Incomplete a-y blockade of the 1st degree (slowdown of a-y conduction).

3.4. a-y blockade of the II degree (Mobitz type I) with periods of Samoilov-va-Wenckebach.

3.5. a-y II-degree blockade (Mobitz type II).

3.6. Incomplete a-y blockade, advanced, high degree 2:1, 3:1.4:1.5:1.

3.7. Complete a-y blockade of the III degree.

3.8. Complete a-y blockade with migration of the pacemaker in the ventricles.

3.9. The Frederick Phenomenon.

3.10. Violation of intraventricular conduction.

3.11. Complete blockade of the right leg of the bundle of His.

3.12. Incomplete blockade of the right leg of the bundle of His.

5. Parasystole.

5.1. Ventricular bradycardia parasystole.

5.2. Parasystoles from the a-y junction.

5.3. Atrial parasystole.

6. Atrioventricular dissociations.

6.1. Incomplete a-y dissociation.

6.2. Complete a-y dissociation (isorhythmic).

7. Flutter and flicker (fibrillation) of the atria and ventricles.

7.1. Bradysystolic form of atrial fibrillation.

7.2. Normosystolic form of atrial fibrillation.

7.3. Tachysystolic form of atrial fibrillation.

7.4. Paroxysmal form of atrial fibrillation.

7.5. Flutter of the stomach.

7.6. Ventricular fibrillation.

7.7. Ventricular asystole.

Note: in the classification of rhythm and conduction disorders, WHO recommendations are taken into account.

8. Classification of infective endocarditis (IE) (421)

1. Acute septic endocarditis (arising as a complication of sepsis - surgical, gynecological, urological, cryptogenic, as well as a complication of injections, invasive diagnostic manipulations).

2. Subacute septic (infectious) endocarditis (due to the presence of an intracardiac or adjacent to the arterial foci of infection leading to recurrent septicemia, embolism.

3. Protracted septic endocarditis (caused by viridescent streptococcus or strains close to it, with the absence of purulent metastases, the prevalence of immunopathological manifestations)

Notes: depending on the previous state of the valve apparatus, all IE are divided into two groups:

- primary, arising on unchanged valves.

- secondary, occurring on altered valves. Cases of the disease lasting up to 2 months. refer to acute over this period - to subacute IE.

Clinical and Laboratory Criteria for Infective Endocarditis Activity

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Hypertensive heart and kidney disease (I13), Hypertensive heart disease (I12), Hypertensive heart disease (heart disease) (I11), Essential [primary] hypertension (I12) I10)

Cardiology

general information

Short description

Recommended
Expert Council
RSE on REM "Republican Center for Health Development"
Ministry of Health and Social Development of the Republic of Kazakhstan
dated November 30, 2015
Protocol No. 18

Arterial hypertension- chronic stable increase in blood pressure, in which the level of systolic blood pressure equal to or more than 140 mm Hg. Art., and (or) the level of diastolic blood pressure, equal to or more than 90 mm Hg. in people who are not receiving antihypertensive drugs [Recommendations of the World Health Organization and the International Society on Hypertension 1999].

I. INTRODUCTION

Protocol name: Arterial hypertension.

ICD-10 codes:

I 10 Essential (primary) hypertension;

I 11 Hypertensive heart disease (hypertension with a primary lesion of the heart);

I 12 Hypertensive (hypertonic) disease with a primary lesion of the kidneys;

I 13 Hypertensive (hypertonic) disease with a primary lesion of the heart and kidneys.

Abbreviations used in the protocol: see Appendix 1 of the clinical protocol.

Protocol development date: 2015

Protocol Users: general practitioners, therapists, cardiologists, endocrinologists, nephrologists, ophthalmologists, neuropathologists.

Class I- Reliable evidence and/or consensus among experts that the procedure or treatment is appropriate, useful and effective.

Class II- Conflicting evidence and/or disagreement between experts on the benefits/effectiveness of a procedure or treatment.

Class IIa- prevailing evidence/opinion in support of benefit/effectiveness.

Class IIb- Benefit/efficacy is not well supported by evidence/expert opinions.

Class III Reliable evidence and/or expert consensus that the procedure or treatment is not useful/effective and in some cases may be harmful.

Level of evidence A. Data from multiple randomized clinical trials or meta-analysis.

Level of evidence B. Data from a single randomized trial or non-randomized trials.

Level of evidence C. Only expert consensus, case studies or standard of care.

Classification

Clinical classification

Table 1- Classification of blood pressure levels (mm Hg)

Categories of blood pressure	GARDEN		DBP
Optimal	< 120	and	< 80
Normal	120 - 129	and/or	80 - 84
high normal	130-139	and/or	85 - 89
AG 1 degree	140 - 159	and/or	90 - 99
AG 2 degrees	160 - 179	and/or	100 - 109
AG 3 degrees	≥ 180	and/or	≥ 110
Isolated systolic hypertension *	≥ 140	and	< 90

Note: The BP category is defined by the higher level of BP, systolic or diastolic. Isolated systolic hypertension should be classified as grade 1, 2, or 3 according to the level of systolic BP.

Cardiovascular risk is subdivided into different categories based on BP, presence of cardiovascular risk factors, asymptomatic target organ damage, diabetes mellitus, symptomatic cardiovascular disease, and chronic kidney disease (CKD) Table 2.

Table 2- Stratification of total CV risk into categories


Note: Asymptomatic hypertensive patients without CVD, CKD, DM, at a minimum, require total CV risk stratification using the SCORE model.

The factors on the basis of which risk stratification is carried out are presented in Table 3.

Table 3- Factors affecting the prognosis of cardiovascular risk

Risk factors

Male gender.

Age (≥ 55 years - men, ≥ 65 years - women).

Smoking.

Dyslipidemia:

- Total cholesterol > 4.9 mmol/L (190 mg/dL) and/or;

- LDL cholesterol >3.0 mmol/L (115 mg/dL), and/or;

- High-density lipoprotein cholesterol: in men<1.0 ммоль/л (40 мг/дЛ), у женщин < 1.2 ммоль/л (46 мг/дЛ), и/или;

- Triglycerides >1.7 mmol/L (150 mg/dL);

Impaired glucose tolerance

Obesity (BMI≥30 kg/m² (height²)).

Abdominal obesity (waist circumference in men ≥ 102 cm, in women ≥ 88 cm).

Family history of early cardiovascular disease (in men<55 лет; у женщин <65 лет).

Pulse pressure (in elderly and senile people) ≥60 mm Hg.

Electrocardiographic signs of LVH (Sokolov-Lyon index >3.5 mV, RaVL >1.1 mV; Cornell index >244 mV x ms).

Echocardiographic signs of LVH [LVH index: >115 g/m² in men, >95 g/m² in women (PPT)*.

Hemorrhages or exudates, papilledema

Carotid wall thickening (intima-media thickness >0.9 mm) or plaque

Velocity of the carotid-femoral pulse wave >10 m/sec.

Ankle-brachial index<0,9.

Diabetes

Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) on two consecutive measurements and/or;

HbA1c >7% (53 mmol/mol) and/or;

Post-exercise plasma glucose >11.0 mmol/L (198 mg/dL).

Cerebrovascular disease: ischemic stroke, cerebral hemorrhage, transient ischemic attack.

IHD: myocardial infarction, angina pectoris, coronary revascularization by PCI or CABG.

Heart failure, including heart failure with preserved ejection fraction.

Clinically manifest lesion of peripheral arteries.

CKD with eGFR<30 мл/мин/1,73м² (ППТ); протеинурия (>300 mg per day).

Severe retinopathy: hemorrhages or exudates, swelling of the optic nipple.

Note: * - the risk is maximal in concentric LVH: an increase in the LVH index with a ratio of wall thickness to radius equal to 0.42.

In patients with hypertension, without CVD, CKD, and diabetes, risk stratification is performed using the Systematic Coronary Risk Assessment (SCORE) model.

Table 4- Overall cardiovascular risk assessment

Recommendations	class a	level b
In asymptomatic hypertensive patients without CVD, CKD, and diabetes, risk stratification using the SCORE model is the minimum requirement.	I	B
Because there is evidence that target organ damage is a predictor of CV mortality regardless of SCORE, screening for target organ damage is reasonable, especially in those at intermediate risk.	IIa	B
Decisions on treatment tactics are recommended to be made depending on the baseline level of total cardiovascular risk.	I	B

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Mandatory examinations at the outpatient stage :

one). Blood pressure measurement in the doctor's office or clinic (office) and out of the office (DMAD and ABPM) are presented in Tables 6, 7, 8, 9.

Office BP - blood pressure measured in a medical facility. The level of office blood pressure is in an independent continuous relationship with the incidence of stroke, myocardial infarction, sudden death, heart failure, peripheral arterial disease, end-stage kidney disease in all age and ethnic groups of patients.

Table 6- Rules for office blood pressure measurement

Allow the patient to sit quietly for a few minutes before measuring blood pressure.

Measure blood pressure at least twice, 1-2 minutes apart, while sitting; if the first two values ​​differ significantly, repeat the measurements. If you think it is necessary, calculate the average value of blood pressure.

To improve measurement accuracy in patients with arrhythmias, such as atrial fibrillation, perform repeated BP measurements. Use a standard cuff 12-13 cm wide and 35 cm long. However, larger and smaller cuffs should be available, respectively, for full (arm circumference > 32 cm) and thin arms. The cuff should be at the level of the heart regardless of the position of the patient.

When using the auscultatory method, systolic and diastolic blood pressure is recorded in phases I and V (disappearance) of the Korotkoff sounds, respectively.

At the first visit, blood pressure should be measured in both arms to identify any possible difference. In this case, they are guided by a higher value of blood pressure

In the elderly, diabetics, and patients with other conditions that may be accompanied by orthostatic hypotension, it is advisable to measure blood pressure 1 and 3 minutes after standing. If blood pressure is measured with a conventional sphygmomanometer, measure heart rate by palpation of the pulse (at least 30 seconds) after re-measuring blood pressure in the sitting position.

Out-of-hospital BP is assessed using 24-hour BP monitoring (ABPM) or home BP measurement (HBP), which is usually measured by the patient himself. Self-measurement of blood pressure requires training under the supervision of a healthcare professional.

Table 7- Determination of arterial hypertension by office and out-of-office blood pressure values

Category	SBP (mmHg)		DBP (mmHg)
Office AD	≥140	and	≥90
Ambulatory blood pressure monitoring (ABPM)
Daytime (waking)	≥ 135	and/or	≥85
Night (sleep)	≥120	and/or	≥70
Daily (average per day)	≥130	and/or	≥80
Home blood pressure (DMAP)	≥135	and/or	≥85

Controlling blood pressure outside of a health care setting has the advantage of provides a large number of blood pressure indicators, which allows you to more reliably assess the existing blood pressure compared to office blood pressure. ABPM and DMAP provide somewhat different information about a patient's BP status and risk and should be considered as complementary. The data obtained by both methods are quite comparable.

Table 8-Clinical indications for out-of-office BP measurement for diagnostic purposes

Clinical indications for ABPM or DMAD

. Suspicion of "white coat hypertension" - AG 1 st in the office (medical facility) - High office BP in patients without target organ damage and at low CV risk

. Suspicion of "masked hypertension":

- High normal blood pressure in the office (medical facility) - Normal office BP in patients with asymptomatic target organ disease and high CV risk - Identification of the "white coat" effect in patients with hypertension - Significant fluctuations in office BP during the same or different visits to the doctor - Vegetative, orthostatic, postprandial, drug hypotension; hypotension during daytime sleep - Elevated office BP or suspected preeclampsia in pregnancy - Identification of true and false resistant hypertension

Specific indications for ABPM

Expressed discrepancies between office and out-of-office blood pressure

Assessment of nocturnal BP drop

Suspicion of nocturnal hypertension or absence of nocturnal BP reduction e.g. in patients with sleep apnea, CKD or diabetes

Assessment of BP variability

"White coat hypertension" is a condition in which, on repeated visits to a medical institution, blood pressure is elevated, and outside it, with SMAD or DMAD, it is normal. But their cardiovascular risk is lower than in patients with persistent hypertension, especially in the absence of diabetes, end-organ damage, cardiovascular disease, or CKD.

"Masked hypertension" is a condition in which blood pressure may be normal in the office and pathologically elevated outside the hospital, but the cardiovascular risk is in the range corresponding to persistent hypertension. These terms are recommended for use in untreated patients.

Table 9- Rules for out-of-office measurement of blood pressure (DMAP and ABPM)

Rules for DMAD

Blood pressure should be measured daily for at least 3-4 days, preferably for 7 days in a row, in the morning and evening. Measurement of blood pressure is carried out in a quiet room, with the patient in a sitting position, with support on the back and support for the arm, after 5 minutes of being at rest.

Each time, two measurements should be taken with an interval between them of 1-2 minutes. Immediately after each measurement, the results are recorded in a standard diary.

Home BP is the average of these results, excluding the first day of monitoring.

Rules for ABPM

ABPM is performed using a portable BP monitor that the patient wears (usually not on the dominant arm) for 24-25 hours, so it provides information about BP during daytime activity and at night while sleeping.

At the moment when the portable monitor is put on the patient, the difference between the initial BP values ​​and the BP values ​​measured by the operator should not exceed 5 mm Hg. If this difference is greater, then the ABPM cuff should be removed and put on again.

The patient is advised to go about their usual daily activities, refraining from heavy exertion, and at the moments of inflation of the cuff, stop, stop talking and keep the hand with the cuff at the level of the heart. In clinical practice, blood pressure measurements are usually taken at intervals of 15 minutes during the day and at intervals of 30 minutes at night.

At least 70% of daytime and nighttime blood pressure measurements must be correctly performed.

2) Laboratory and instrumental examination:

Hemoglobin and / hematocrit;

Urinalysis: urinary sediment microscopy, microalbuminuria, protein (qualitative) dipstick test (I B).

Biochemical analysis:

Determination of glucose in blood plasma;

Determination of total cholesterol, LDL cholesterol, HDL cholesterol, TG in blood serum;

Determination of potassium and sodium in blood serum;

Determination of uric acid in blood serum;

Determination of serum creatinine (with calculation of GFR) (I B).

ECG in 12 standard leads (I C);

Echocardiography (IIaB).

Additional studies at the outpatient level:

Glycated hemoglobin (if fasting plasma glucose >5.6 mmol/L (102 mg/dL) on two different tests or pre-existing diabetes) to confirm or rule out diabetes;

Determination of protein in the urine (quantitative) with a positive result of a qualitative protein in the urine (if the rapid analysis is positive) - to detect CKD;

The concentration of sodium and potassium in the urine and their ratio - to exclude primary or secondary hyperaldosteronism (IB);

SMAD - to confirm hypertension;

24-hour Holter ECG monitoring - to determine the nature of arrhythmias;

Ultrasound of the carotid arteries (intima-media thickness) (IIaB) - to detect atherosclerosis and plaque in the carotid arteries;

Dopplerography of the vessels of the abdominal cavity and peripheral arteries (IIaB) - to detect atherosclerosis;

Pulse wave velocity measurement (IIaB) - to determine aortic stiffness;

Measurement of the ankle-brachial index (IIaB) - to determine the degree of damage to peripheral arteries and atherosclerosis in general;

Fundus examination (IIaB) - to detect hypertensive retinopathy.

The minimum list of examinations that must be carried out upon referral for planned hospitalization: in accordance with the internal regulations of the hospital, taking into account the current order of the authorized body in the field of healthcare.

Basic (mandatory) diagnostic examinations carried out at the hospital level(during hospitalization, diagnostic examinations are performed that are not carried out at the outpatient level).

In-depth search for signs of damage to the brain CT and MRI (IIb C), heart (echocardiography (IIa B), kidneys (urinary sediment microscopy, microalbuminuria, protein (qualitative) protein determination using test strips (IB)) and vessels (vascular dopplerography) abdominal cavity and peripheral arteries, measurement of pulse wave velocity and ankle-brachial index (IIa B) Mandatory in resistant and complicated hypertension.

Additional diagnostic examinations performed at the inpatient level (during hospitalization, diagnostic examinations are performed that are not performed at the outpatient level).

List of basic and additional diagnostic measures at the stage of emergency medical care

Basic (mandatory) diagnostic examinations carried out at the stage of emergency medical care :

Measurement of blood pressure (table 6) and pulse;

ECG in 12 standard leads.

Diagnostic Criteria for Making a Diagnosis

Initial examination of a patient with hypertension should be directed to:

Confirmation of the diagnosis of hypertension;

Identification of the causes of secondary hypertension;

Assessment of cardiovascular risk, target organ damage, and clinically manifest cardiovascular or renal disease.

This requires: measurement of blood pressure, history taking, including family history, physical examination, laboratory tests, and additional diagnostic tests.

Complaints and anamnesis(table 10)

Check for complaints:

A) headache, dizziness, blurred vision, sensory or motor disorders;

B) chest pain, shortness of breath, fainting, palpitations, arrhythmias, swelling of the ankles;

C) thirst, polyuria, nocturia, hematuria;

D) cold extremities, intermittent lameness;

D) snoring.

When collecting a medical history, you should establish:

Time of first diagnosis of hypertension;

BP values ​​in the past and present;

Assess previous antihypertensive therapy.

Table 10- Collection of individual and family medical history

1. Duration and previous values ​​of elevated blood pressure, including home

2. Risk factors a) Family and personal history of hypertension and cardiovascular disease. b) Family and personal history of dyslipidemia. c) Family and personal history of diabetes mellitus (drugs, glycemia, polyuria). d) smoking. e) Features of nutrition. f) Dynamics of body weight, obesity. g) Level of physical activity. h) Snoring, sleep apnea (collection of information also from a partner). i) Low birth weight.

3. Secondary hypertension a) Family history of CKD (polycystic kidney disease). b) A history of kidney disease, urinary tract infections, hematuria, abuse of painkillers (parenchymal kidney disease). c) Taking medications such as oral contraceptives, licorice, carbenoxolones, vasoconstrictor nasal drops, cocaine, amphetamines, gluco- and mineralocorticoids, non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine. d) Repeated episodes of sweating, headache, anxiety, palpitations (pheochromocytoma). e) Periodic muscle weakness and convulsions (hyperaldosteronism); f) Symptoms suggestive of thyroid disease.

4. Treatment of hypertension a) Current antihypertensive therapy. b) Prior antihypertensive therapy. c) Data on adherence or lack of adherence to treatment. d) Efficacy and side effects of drugs.

Physical examination(Table 11) .
Physical examination should include establishing or confirming the diagnosis of hypertension (Table 6), determining CV risk, signs of secondary hypertension, and organ damage. Palpation of the pulse and auscultation of the heart may reveal arrhythmias. All patients should have their resting heart rate measured. Tachycardia indicates an increased risk of heart disease. An irregular pulse may indicate atrial fibrillation (including asymptomatic). An additional examination to look for vascular lesions is indicated if, when measuring blood pressure in both arms, a difference in SBP > 20 mm Hg is detected. and DBP >10 mmHg

Table 11- Physical examination data indicating organ pathology and secondary nature of hypertension

Signs of target organ damage

. Brain: impaired mobility or sensation.

. Retina: changes in the fundus.

. Heart: pulse, localization and characteristics of the apex beat, arrhythmia, gallop rhythm, rales in the lungs, peripheral edema.

. Peripheral arteries: absence, weakening or asymmetry of the pulse, cold extremities, ischemic ulcers on the skin.

. Carotid arteries: systolic murmur.

Signs of visceral obesity:

. Body weight and height.

. The increase in waist circumference in the standing position, measured between the edge of the last rib and the ilium.

. Increase in body mass index [body weight, (kg)/height, (m)²].

Signs of secondary hypertension

. Signs of Itsenko-Cushing's syndrome.

. Skin manifestations of neurofibromatosis (pheochromocytoma).

. Enlargement of the kidneys on palpation (polycystic).

. The presence of noise in the projection of the renal arteries (renovascular hypertension).

. Murmurs in the heart (coarctation and other diseases of the aorta, disease of the arteries of the upper extremities).

. Decreased pulsation and blood pressure in the femoral artery, compared with the simultaneous measurement of blood pressure in the arm (coarctation and other diseases of the aorta, damage to the arteries of the lower extremities).

. The difference between blood pressure on the right and left hands (coarctation of the aorta, stenosis of the subclavian artery).

Laboratory Criteria
Laboratory and instrumental examinations are aimed at obtaining data on the presence of additional risk factors, damage to target organs and secondary hypertension. Investigations should be carried out in order from the simplest to the most complex. Details of laboratory studies are presented below in table 12.

Table 12-Laboratory criteria for factors influencing the prognosis of cardiovascular risk

Risk factors

Dyslipidemia:

Total cholesterol > 4.9 mmol/L (190 mg/dL) and/or

LDL cholesterol >3.0 mmol/L (115 mg/dL), and/or

High-density lipoprotein cholesterol: in men<1.0 ммоль/л (40 мг/дЛ), у женщин < 1.2 ммоль/л (46 мг/дЛ), и/или

Triglycerides >1.7 mmol/L (150 mg/dL)

Fasting plasma glucose 5.6 - 6.9 mmol / l (102-125 mg / dL).

Impaired glucose tolerance.

Asymptomatic target organ damage

CKD with eGFR 30-60 ml/min/1.73 m² (BSA).

Microalbuminuria (30-300 mg daily) or albumin to creatinine ratio (30-300 mg/g; 3.4-34 mg/mmol) (preferably in morning urine).

Diabetes

Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) on two consecutive measurements and/or

HbA1c >7% (53 mmol/mol) and/or

Post-exercise plasma glucose >11.0 mmol/L (198 mg/dL).

Clinically manifest cardiovascular or renal disease

CKD with eGFR<30 мл/мин/1,73м² (ППТ); протеинурия (>300 mg per day).

Instrumental criteria:

Increased blood pressure values ​​(see table 7);

ECG in 12 standard leads (Sokolov-Lyon index

>3.5 mV, RaVL >1.1 mV; Cornell index >244 mV x ms) (IC);

Echocardiography (LVH index LVH: >115 g/m² in men, >95 g/m² in women) (IIaB);

Carotid ultrasound (intima-media thickness >0.9 mm) or plaque (IIaB);

Pulse wave velocity measurement>10 m/s (IIaB);

Ankle-brachial index measurement<0,9 (IIaB);

Hemorrhages or exudates, papilledema on fundoscopy (IIaB).

Indications for expert advice

A. Neurologist:

1 acute disorders of cerebral circulation

Stroke (ischemic, hemorrhagic);

Transient disorders of cerebral circulation.

2. Chronic forms of vascular pathology of the brain:

Initial manifestations of insufficient blood supply to the brain;

Encephalopathy.

B. Optometrist:

Hemorrhages in the retina;

Swelling of the nipple of the optic nerve;

Retinal disinsertion;

progressive loss of vision.

V. Nephrologist:

Exclusion of symptomatic nephrogenic hypertension, CKD IV-V st.

G. Endocrinologist:

Exclusion of symptomatic endocrine hypertension, diabetes.

Differential Diagnosis

Differential Diagnosis(table 13)

All patients should be screened for secondary forms of hypertension, which includes a clinical history, physical examination, and routine laboratory tests (Table 13).

Table 13- Clinical signs and diagnosis of secondary hypertension

	Clinical indicators			Diagnostics
Common Causes	Anamnesis	Inspection	Laboratory research	First line studies	Additional/confirmatory studies
Kidney parenchyma damage	History of urinary tract infection, obstruction, hematuria, overuse of painkillers, family history of polycystic kidney disease	Abdominal lumps/lumps (polycystic kidney disease)	Proteinuria, erythrocytes, leukocytes in urine, decreased GFR	Ultrasound of the kidneys	Detailed examination of the kidneys
Renal artery stenosis	Fibromuscular dysplasia: hypertension of young age (especially in women) Atherosclerotic stenosis: sudden onset of hypertension, deterioration or difficulty in control, acute pulmonary edema	Noise on auscultation of the renal arteries	Kidney length difference >1.5 cm (renal ultrasound), rapid deterioration of kidney function (spontaneous or in response to renin-angiotensin-aldosterone system blockers)	2D dopplerography of the kidneys	MRI, spiral CT, intra-arterial digital angiography
Primary aldosteronism	Family history of muscle weakness, hypertension at an early age, or CV complications before age 40	Arrhythmias (with severe hypokalemia)	Hypokalemia (spontaneous or diuretic-induced), incidental finding of adrenal tumor	Aldosterone/renin ratio under standardized conditions (with correction of hypokalemia and discontinuation of drugs that affect the RAAS	Sodium loading, saline infusion, flurocortisone suppression, or captopril test; CT scan of the adrenal glands; adrenal vein biopsy
Pheochromocytoma	Paroxysms of increased blood pressure or crises with existing hypertension; headache, sweating, palpitations, pallor, family history of pheochromocytoma	Skin manifestations of neurofibromatosis (cafe-au-lait spots, neurofibromas)	Incidental finding of tumors of the adrenal glands (or outside the adrenal glands)	Measurement of conjugated urinary metanephrines or free plasma metanephrines	CT or MRI of the abdomen and pelvis; meta-123 I-benzylguanidine scintigraphy; genetic testing for mutations
Cushing's syndrome	Rapid weight gain, polyuria, polydipsia, psychological disorders	Typical appearance (central obesity, moon face, striae, hirsutism)	hyperglycemia	Daily excretion of cortisol in the urine	Dexamethasone test

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:

Maximum reduction in the risk of developing SSO and death;

Correction of all modifiable risk factors (smoking, dyslipidemia, hyperglycemia, obesity);

Prevention, slowing down the rate of progression and / or reducing POM;

Treatment of clinically manifest and concomitant diseases - IHD, CHF, DM, etc.;

Achievement of target blood pressure levels<140/90 мм.рт.ст. (IA);

Achievement of target blood pressure levels in patients with diabetes<140/85 мм.рт.ст. (IA).

Treatment tactics:

Lifestyle modification: salt restriction, alcohol restriction, weight loss, regular physical activity, smoking cessation (Table 14).

Recommendations	class a	Level b,d	Level b,e
It is recommended to limit salt intake to 5-6 g/day	I	A	B
It is recommended to limit alcohol consumption to no more than 20-30 g (ethanol) per day for men and no more than 10-20 g per day for women.	I	A	B
It is recommended to increase the intake of vegetables, fruits, low-fat dairy products.	I	A	B
In the absence of contraindications, it is recommended to reduce body weight to a BMI of 25 kg/m² and waist circumference to<102 см у мужчин и <88 см у женщин.	I	A	B
Regular physical activity is recommended, for example, at least 30 minutes of moderate dynamic physical activity for 5-7 days a week.	I	A	B
It is recommended that all smokers be given advice on quitting and offer appropriate assistance.	I	A	B

A Recommendation class
b Level of evidence
c References supporting levels of evidence


d based on effect on BP and CV risk
e Based on outcome studies

Medical treatment(Tables 15-16, Figure 1-2, Appendix 2 of the clinical protocol).

All major groups of drugs - diuretics (thiazides, chlorthalidone and indapamide), beta-blockers, calcium antagonists, ACE inhibitors and angiotensin receptor blockers are suitable and recommended for initial and maintenance antihypertensive therapy, either as monotherapy or in certain combinations with each other (IA).

Some drugs may be considered preferable in specific situations because they have been used in these situations in clinical trials or have been shown to be more effective in specific types of IIaC target organ damage (Table 15).

Table 15- Conditions requiring the choice of individual drugs

states	Preparations
Asymptomatic target organ damage
LVH
Asymptomatic atherosclerosis	Calcium antagonists, ACE inhibitors
microalbuminuria	ACE inhibitor, ARB
Impaired kidney function	ACE inhibitor, ARB
Cardiovascular event
History of stroke	Any drug that effectively lowers blood pressure
History of myocardial infarction	BB, ACE inhibitor, ARB
angina pectoris	BB, calcium antagonists
Heart failure	Diuretics, BBs, ACE inhibitors, ARBs, mineralocorticoid receptor antagonists
aortic aneurysm	BB
Atrial fibrillation (prevention)	Can be an ARB, ACE inhibitor, beta-blocker, or a mineralocorticoid receptor antagonist
Atrial fibrillation (ventricular rhythm control)	BB, calcium antagonists (non-dihydropyridine)
End-stage CKD/Proteinuria	ACE inhibitor, ARB
Peripheral arterial disease	ACE inhibitors, calcium antagonists
Other
ISAG (elderly and senile age)
metabolic syndrome	ACE inhibitors, calcium antagonists, ARBs
Diabetes	ACE inhibitor, ARB
Pregnancy	Methyldopa, BB, calcium antagonists
Negroid race	Diuretics, calcium antagonists

Abbreviations: ACE - angiotensin-converting enzyme, ARB - angiotensin receptor blocker, BP - blood pressure, CKD - ​​chronic kidney disease, ISAH - isolated systolic arterial hypertension, LVH - left ventricular hypertrophy

Monotherapy can effectively lower BP in only a limited number of hypertensive patients (low to moderate CV risk), and most patients require a combination of at least two drugs to achieve BP control.

Picture 1- Approaches to the choice of monotherapy or combination therapy for hypertension.

The most widely used two-component drug combinations are shown in the diagram in Figure 2.

Figure 2- Possible combinations of classes of antihypertensive drugs.

Green continuous lines are preferred combinations. Green outline - useful combinations (with some restrictions). Black dotted line - possible combinations, but little studied. The red line is an unrecommended combination. Although verapamil and diltiazem are sometimes used in combination with beta-blockers for pulse control in patients with atrial fibrillation, only dihydroperidine derivatives should normally be used with beta-blockers.

Table 16- Absolute and relative contraindications to the use of antihypertensive drugs

Preparations	Absolute	Relative (possible)
Diuretics (thiazides)	Gout	metabolic syndrome Pregnancy Hypercalcemia hypokalemia
Beta blockers Calcium antagonists (dihydropyridines)	Asthma Atrioventricular blockade of 2-3 degrees	metabolic syndrome Decreased glucose tolerance Athletes and physically active patients COPD (except beta-blockers with vasodilatory effect) Tachyarrhythmias Heart failure
Calcium antagonists (verapamil, diltiazem)	Atrioventricular block (2-3 degrees or blockade of three bundles) Severe LV failure Heart failure
ACE inhibitors	Pregnancy Angioedema Hyperkalemia Bilateral renal artery stenosis
Angiotensin receptor blockers Mineralocorticoid receptor antagonists	Pregnancy Hyperkalemia Bilateral renal artery stenosis Acute or severe renal failure (eGFR<30 мл/мин) Hyperkalemia	Women capable of childbearing

Medical treatment provided at the inpatient level see above (Table 15-16, Figure 1-2, Appendix 2 of the Clinical Protocol) .

Drug treatment provided at the stage of emergency emergency care

At this stage, short-acting drugs are used, including labetalol (not registered in the Republic of Kazakhstan), sodium nitroprusside (not registered in the Republic of Kazakhstan), nicardipine, nitrates, furosemide for parenteral administration, but in severe patients, the doctor should approach treatment individually. Sharp hypotension and a decrease in perfusion of vital organs, especially the brain, should be avoided.

Other treatments: approaches to treatment for various conditions (tables 17-26) .

Treatment tactics for white-coat hypertension and masked hypertension

In individuals with white-coat hypertension, therapeutic intervention should be limited to lifestyle changes only, but such a decision should be followed by close follow-up (IIaC).

In patients with white-coat hypertension with a higher CV risk due to metabolic disorders or asymptomatic target organ damage, medical therapy may be appropriate in addition to lifestyle changes (IIbC).

In masked hypertension, it is advisable to prescribe antihypertensive drug therapy along with lifestyle changes, since it has been repeatedly established that this type of hypertension is characterized by a cardiovascular risk very close to that of office and out-of-office hypertension (IIaC).

The tactics of antihypertensive therapy in elderly and senile patients are presented in Table 17.

Table 17- Tactics of antihypertensive therapy in elderly and senile patients

Recommendations	class a	level b
There is evidence to recommend elderly and senile hypertensive patients with SBP levels ≥160 mmHg. decrease in SBP to the level of 140-150 mm Hg.	I	A
In hypertensive patients aged<80 лет, находящихся в удовлетворительном общем состоянии, антигипертензивная терапия может считаться целесообразной при САД ≥140 мм рт.ст., а целевые уровни САД могут быть установлены <140 мм рт.ст., при условии хорошей переносимости терапии.	IIb	C
In patients over 80 years of age with a baseline SBP ≥160 mm Hg, a reduction in SBP to the range of 140-150 mm Hg is recommended, provided that the patients are in good physical and mental condition.	I	V
In debilitated elderly and senile patients, it is recommended to leave the decision on antihypertensive therapy to the discretion of the attending physician, subject to monitoring of the clinical effectiveness of treatment.	I	C
When a hypertensive patient on antihypertensive therapy reaches 80 years of age, it is reasonable to continue this therapy if it is well tolerated.	IIa	C
In elderly and senile hypertensive patients, any antihypertensive drug can be used, although diuretics and calcium antagonists are preferred in isolated systolic hypertension.	I	A

Young adult patients. In the case of an isolated increase in brachial systolic pressure in young people (with DBP<90 мм рт.ст), центральное АД у них чаще всего в норме и им рекомендуется только модификация образа жизни. Медикаментозная терапия может быть обоснованной и целесообразной, и, особенно при наличии других факторов риска, АД должно быть снижено до<140/90 мм.рт.ст.

Antihypertensive therapy in women. Medical therapy is recommended for severe hypertension (SBP >160 mmHg or DBP >110 mmHg) (IC), Table 18.

Recommendations	class a	level b
Hormone replacement therapy and estrogen receptor modulators are not recommended and should not be used for primary or secondary prevention of cardiovascular disease. If their appointment to a woman of relatively young age in perimenopause is considered to eliminate severe symptoms of menopause, then it is necessary to weigh the benefits and potential risks.	III	A
Drug therapy may also be appropriate in pregnant women with a persistent increase in blood pressure to ≥150/95 mmHg, as well as in patients with blood pressure ≥140/90 mmHg. in the presence of gestational hypertension, subclinical target organ damage or symptoms.	IIb	C
In women at high risk of preeclampsia, low-dose aspirin may be appropriate from 12 weeks of gestation until delivery if the risk of gastrointestinal bleeding is low.	IIb	V
In women of childbearing potential, RAS blockers are not recommended and should be avoided.	III	C
The preferred antihypertensive drugs in pregnancy are methyldopa, labetolol, and nifedipine. In urgent cases (preeclampsia), intravenous labetolol or intravenous infusion of sodium nitroprusside is advisable.	IIa	C

Tactics of management of patients with hypertension in metabolic syndrome(table 19).

Table 19- Antihypertensive therapy in MS

Recommendations	class a	level b
Lifestyle changes, in particular weight loss and physical activity.	I	V
Drugs that potentially improve insulin sensitivity, such as RAS and AK blockers, are preferred. BB (with the exception of vasodilators) and diuretics (preferably in combination with a potassium-sparing diuretic).	IIa	C
It is recommended to prescribe antihypertensive drugs with extreme caution in patients with metabolic disorders with BP ≥140/90 mmHg, after a certain period of lifestyle changes, maintain BP<140/90 мм.рт.ст.	I	V
In the metabolic syndrome with high normal blood pressure, antihypertensive drugs are not recommended.	III	A

Tactics of managing patients with hypertension in diabetes mellitus(table 20).

Target BP<140/85 мм.рт.ст (IA).

Table 20- Antihypertensive therapy in diabetes mellitus

Recommendations	class a	level b
While the appointment of antihypertensive drug therapy for diabetic patients with SBP ≥160 mm Hg. is mandatory, it is strongly recommended to start pharmacotherapy also at SBP ≥140 mm Hg.	I	A
In diabetic patients, all classes of antihypertensive drugs are recommended and can be used. RAS blockers may be preferred, especially in the presence of proteinuria or microalbuminuria.	I	A
It is recommended to select drugs individually, taking into account concomitant diseases.	I	C
Coadministration of two RAS blockers is not recommended and should be avoided in diabetic patients.	III	V

Management of patients with nephropathy(table 21).

Table 21- Antihypertensive therapy for nephropathy

Recommendations	class a	level b
Possible decrease in SBP to<140мм.рт.ст	IIa	V
In the presence of severe proteinuria, SBP may decrease to<130 мм.рт.ст., при этом необходим контроль изменений СКФ.	IIb	V
RAS blockers are more effective at reducing albuminuria than other antihypertensive drugs and are indicated in hypertensive patients with microalbuminuria or proteinuria.	I	A
Achieving target BP usually requires combination therapy; it is recommended to combine RAS blockers with other antihypertensive drugs.	I	A
Although the combination of two RAS blockers is more effective in reducing proteinuria, its use is not recommended.	III	A
In CKD, aldosterone antagonists should not be recommended, especially in combination with a RAS blocker, due to the risk of a sharp deterioration in kidney function and hyperkalemia.	III	C

Abbreviations: BP, blood pressure, RAS, renin-angiotensin system, CKD, chronic kidney disease, GFR, glomerular filtration rate, SBP, systolic blood pressure.

Tactics of treatment in cerebrovascular disease(table 22).

Table 22- Antihypertensive therapy in cerebrovascular diseases

Recommendations	class a	level b
In the first week after an acute stroke, antihypertensive intervention is not recommended, regardless of BP, although very high SBP should be managed according to the clinical situation.	III	V
In hypertensive patients with a history of TIA or stroke, antihypertensive therapy is recommended, even if the initial SBP is in the range of 140-159 mmHg.	I	V
For hypertensive patients with a history of TIA or stroke, it is advisable to set the target SBP values ​​at the level<140 мм.рт.ст.	IIa	V
In elderly hypertensive patients with a history of TIA or stroke, SBP values ​​at which antihypertensive therapy is prescribed, as well as target values, may be somewhat higher.	IIa	V
For the prevention of stroke, any antihypertensive therapy regimens that provide an effective reduction in blood pressure are recommended.	I	A

Abbreviations: BP, blood pressure; SBP, systolic blood pressure; TIA, transient ischemic attack.

Tactics of treatment of hypertensive patients with heart disease.

Target SBP: <140 мм.рт.ст. (IIaB), таблица 23.

Table 23- Antihypertensive therapy for heart disease

Recommendations	class a	level b
Patients with hypertension who have recently suffered a myocardial infarction are recommended beta-blockers. For other manifestations of coronary artery disease, any antihypertensive drugs can be prescribed, but beta-blockers and calcium antagonists that relieve symptoms (for angina pectoris) are preferred.	I	A
Diuretics, beta-blockers, ACE inhibitors or ARBs, and mineralocorticoid receptor antagonists are recommended to reduce mortality and the need for hospitalization in patients with heart failure or severe left ventricular dysfunction.	I	A
In patients at risk for new or recurrent atrial fibrillation, it is reasonable to prescribe ACE inhibitors and ARBs as antihypertensive agents (as well as beta-blockers and mineralocorticoid receptor antagonists if there is concomitant heart failure).	IIa	C
Antihypertensive drugs are recommended for all patients with LVH.	I	V
In patients with LVH, it is reasonable to start treatment with one of the drugs that has demonstrated a more pronounced effect on the regression of LVH, i.e., an ACE inhibitor, an ARB, and a calcium antagonist.	IIa	V

Abbreviations: ACE, angiotensin-converting enzyme, ARBs, angiotensin receptor blockers, LVH, left ventricular hypertrophy, SBP, systolic blood pressure.

Tactics of treatment of hypertensive patients with atherosclerosis, arteriosclerosis and peripheral arterial lesions.
Target SBP: <140/90 мм.рт.ст. (IА), так как у них имеется высокий риск инфаркта миокарда, инсульта, сердечной недостаточности и сердечно-сосудистой смерти (таблица 24).

Table 24- Antihypertensive therapy for atherosclerosis, arteriosclerosis, or peripheral arterial disease

Recommendations	class a	level b
In carotid atherosclerosis, it is advisable to prescribe calcium antagonists and ACE inhibitors, since these drugs slowed the progression of atherosclerosis more effectively than diuretics and beta-blockers.	IIa	V
It is advisable to prescribe any antihypertensive drugs to patients with hypertension with PWV of more than 10 m/sec, provided that the level of blood pressure is steadily reduced to<140/90 мм.рт.ст.	IIa	V
With careful monitoring, beta-blockers may be considered for the treatment of hypertension in patients with PAD, as they have not been shown to aggravate PAD symptoms.	IIb	A

Abbreviations: ACE, angiotensin-converting enzyme; BP, blood pressure; PPA, peripheral arterial disease; PWV, pulse wave velocity.

Treatment strategy for resistant hypertension(table 25).

Table 25- Antihypertensive therapy for resistant hypertension

Recommendations	class a	level b
It is recommended to check whether the drugs used in the multicomponent regimen have any blood pressure lowering effect and stop them if their effect is absent or minimal.	I	C
In the absence of contraindications, it is reasonable to prescribe mineralocorticoid receptor antagonists, amiloride, and the alpha-blocker doxazosin.	IIa	V
When drug therapy fails, invasive procedures such as renal denervation and baroreceptor stimulation may be considered.	IIb	C
In view of the lack of data on the long-term efficacy and safety of renal denervation and baroreceptor stimulation, it is recommended that these procedures be performed by an experienced physician, and diagnostics and monitoring should be carried out in specialized centers for hypertension.	I	C
It is recommended to consider the possibility of using invasive techniques only in patients with truly resistant hypertension, with office SBP ≥160 mm Hg. or DBP ≥110 mmHg and an increase in blood pressure, confirmed by ABPM.	I	C

Abbreviations: ABPM, 24-hour ambulatory blood pressure monitoring, BP, blood pressure, DBP, diastolic blood pressure, SBP, systolic blood pressure.

malignant hypertension is an emergency, clinically manifested as a significant increase in blood pressure in combination with ischemic damage to target organs (retina, kidney, heart, or brain). Due to the low incidence of this condition, there are no high-quality controlled studies with new drugs. Modern therapy is based on drugs that can be administered intravenously with dose titration, which allows you to act quickly, but smoothly, to avoid severe hypotension and aggravation of ischemic damage to target organs. Among the most commonly used drugs for intravenous use in severely ill patients are labetalol, sodium nitroprusside, nicardipine, nitrates and furosemide. The choice of drug is at the discretion of the physician. If diuretics cannot cope with the volume overload, ultrafiltration or temporary dialysis can sometimes help.

Hypertensive crises and emergencies. Emergency situations in hypertension include a marked increase in SBP or DBP (>180 mmHg or >120 mmHg, respectively), accompanied by a threat or progression

Target organ damage, such as severe neurological signs, hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, acute left ventricular failure, acute pulmonary edema, aortic dissection, renal failure, or eclampsia.

An isolated sharp increase in blood pressure without signs of acute damage to target organs (hypertensive crises), which often develops against the background of a break in therapy, a decrease in the dose of drugs, and anxiety, does not belong to emergency situations and must be corrected by resuming or intensifying drug therapy and stopping anxiety.

Surgical intervention .
Renal artery sympathetic plexus catheter ablation, or renal denervation, is the bilateral destruction of the nerve plexuses along the renal artery by radiofrequency ablation with a catheter inserted percutaneously through the femoral artery. The mechanism of this intervention is to disrupt the sympathetic effect on the resistance of the renal vessels, on renin release and sodium reabsorption, and to reduce the increased sympathetic tone in the kidneys and other organs observed in hypertension.

Indication for the procedure is resistant uncontrolled essential hypertension (systolic blood pressure when measuring office and DMAD - more than 160 mm Hg or 150 mm Hg - in patients with diabetes mellitus, confirmed by ABPM≥130/80 mm Hg see table 7), despite the triple therapy carried out by a specialist in hypertension (table 25) and the patient's satisfactory adherence to treatment.

Contraindications to the procedure are renal arteries less than 4 mm in diameter and less than 20 mm in length, manipulations on the renal arteries (angioplasty, stenting) in history, renal artery stenosis more than 50%, renal failure (GFR less than 45 ml / min. / 1.75 m²), vascular events (MI, episode of unstable angina, transient ischemic attack, stroke) less than 6 months. before the procedure, any secondary form of hypertension.

Preventive actions(prevention of complications, primary prevention for PHC level, indicating risk factors):
- home monitoring of blood pressure (DMAD);

Diet with restriction of animal fats, rich in potassium;

Reducing the intake of table salt (NaCI) to 4.5 g / day;

Reducing excess body weight;

Stop smoking and limit alcohol consumption;

Regular dynamic physical activity;

Psychorelaxation;

Compliance with the regime of work and rest;

Group lessons in AG schools;

Compliance with the drug regimen.

Treatment of risk factors associated with hypertension(table 26).

Table 26- Treatment of risk factors associated with hypertension

Recommendations	class a	level b
It is recommended to prescribe statins to hypertensive patients with moderate to high cardiovascular risk; low density lipoprotein cholesterol target<3,0 ммоль/л (115 мг/дл).	I	A
In the presence of clinically manifest coronary artery disease, statin administration and a target value of low-density lipoprotein cholesterol are recommended.<1,8 ммоль/л (70 мг/дл).)	I	A
Antiplatelet therapy, in particular low-dose aspirin, is recommended in hypertensive patients who have already experienced cardiovascular events.	I	A
It is reasonable to prescribe aspirin to hypertensive patients with impaired renal function or high cardiovascular risk, provided that blood pressure is well controlled.	IIa	V
Aspirin is not recommended for cardiovascular prophylaxis in low- and moderate-risk hypertensive patients in whom the absolute benefits and absolute harms of such therapy are equivalent.	III	A
In hypertensive patients with diabetes, the HbA1c target during antidiabetic therapy is<7,0%.	I	V
In more debilitated elderly patients with a long duration of diabetes, a large number of comorbidities and a high risk, HbA1c targets are reasonable.<7,5-8,0%.	IIa	C

Further tactics of the medical worker :

Achievement and maintenance of target blood pressure levels.

When prescribing antihypertensive therapy, scheduled patient visits to the doctor to assess the tolerability, efficacy and safety of treatment, as well as to monitor the implementation of the recommendations received, are carried out at intervals of 2-4 weeks until the target level of blood pressure is reached (delayed response may gradually develop over the first two months).

After reaching the target level of blood pressure against the background of ongoing therapy, follow-up visits for patients medium to low risk are planned at intervals of 6 months.

For the sick at high and very high risk, and for those with low adherence to treatment intervals between visits should not exceed 3 months.

At all planned visits, it is necessary to monitor the implementation of treatment recommendations by patients. Since the state of the target organs changes slowly, it is not advisable to conduct a follow-up examination of the patient to clarify their condition more than once a year.

For persons with high normal BP or white-coat hypertension Even if they are not receiving therapy, they should be followed up regularly (at least once a year) with measurements of office and ambulatory BP, and assessment of cardiovascular risk.

For dynamic monitoring, telephone contacts with patients should be used to improve adherence to treatment!

To improve adherence to treatment, it is necessary that there is feedback between the patient and the medical staff (patient self-management). For this purpose, it is necessary to use home monitoring of blood pressure (sms, e-mail, social networks or automated methods of telecommunication), aimed at encouraging self-control of the effectiveness of treatment, adherence to doctor's prescriptions.

Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol.

Table 27-Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol

^ Main clinical characteristics of hypertensive crisis

Blood pressure: diastolic usually above 140 mmHg.

Changes in the fundus: hemorrhages, exudates, swelling of the optic nerve papilla.

Neurological changes: dizziness, headaches, confusion, drowsiness, stupor, nausea, vomiting, loss of vision, focal symptoms (neurological deficit), loss of consciousness, coma.

Depending on the predominance of certain clinical symptoms, types of hypertensive crises are sometimes distinguished: neurovegetative, edematous, convulsive.

Formulation of diagnoses for certain diseases of the cardiovascular system

Main disease: Hypertensive disease of the 2nd degree, stage II, risk 3. Atherosclerosis of the aorta, carotid arteries.

Coded I ^ 10 as essential (primary) arterial hypertension.

Main disease: Hypertensive disease of the 2nd degree, stage III, risk 4. Atherosclerosis of the aorta, coronary arteries. Complications: CHF stage IIA (FC II). Concomitant disease: Sequelae of Ischemic Stroke (March 2001)

Coded I 11.0 as hypertension with a primary lesion of the heart with congestive heart failure.

Main disease: Hypertensive disease of the 2nd degree, stage III, risk 4. Atherosclerosis of the aorta, coronary arteries. ischemic heart disease. Angina pectoris, FC P. Postinfarction cardiosclerosis. Complications: Aneurysm of the left ventricle. CHF stage IIA (FC II). Right-sided hydrothorax. Nephrosclerosis. Chronic renal failure. Concomitant disease: Chronic gastritis.

Coded I 13.2 as hypertension with a primary lesion of the heart and kidneys with congestive heart failure and renal failure. This diagnosis is correct if the cause of hospitalization of the patient was hypertension. If hypertension is an underlying disease, one or another form of coronary heart disease is coded (see below).

In the case of a hypertensive crisis, codes I11-I13 are used (depending on the presence of involvement of the heart and kidneys). The code ON can only be if signs of damage to the heart or kidneys are not detected.

By virtue of the foregoing, wrong diagnosis:

^ Underlying disease: Hypertension, stage III. Concomitant disease: Varicose veins of the lower extremities.

The main mistake is v the fact that the doctor indicated the third stage of hypertension, which is established in the presence of one or more associated diseases, but they are not indicated in the diagnosis. In this case the code can be used ON, which is most likely not true. 38

^ Formulation of diagnoses for certain diseases of the cardiovascular system

Secondary (symptomatic) arterial hypertension

I15 Secondary hypertension

I15.0 Renovascular hypertension

I15.1 Hypertension secondary to others

kidney damage

I15.2 Hypertension secondary to endo

critical disorders

I15.8 Other secondary hypertension

I15.9 Secondary hypertension, unspecified

If arterial hypertension is secondary, that is, it can be considered as a symptom of a disease, then the clinical diagnosis is formed in accordance with the rules related to this disease. ICD-10 codes I 15 used in the event that arterial hypertension as the leading symptom determines the main costs for the diagnosis and treatment of the patient.

Examples of the formulation of the diagnosis

The patient, who applied in connection with arterial hypertension, had an increase in serum creatinine, proteinuria. He is known to have been suffering from type 1 diabetes for a long time. Here are some formulations of diagnoses that occur in this situation.

^ Underlying disease: Diabetes mellitus type 1, stage of compensation. Complication: diabetic nephropathy. arterial hypertension. Chronic renal failure, stage I

^ Underlying disease: Hypertensive disease of the 3rd degree, stage III. Complications: Nephrosclerosis. Chronic renal failure, stage I. Concomitant disease: Diabetes mellitus type 1, stage of compensation.

^ Underlying disease: Arterial hypertension, stage III, against the background of diabetic nephropathy. Complication: Chronic renal failure, stage I. Concomitant disease: Diabetes mellitus type 1, stage of compensation.

Taking into account the fact that arterial hypertension in the patient is associated with diabetic nephropathy, diabetes mellitus is compensated, and the main medical measures were aimed at correcting high blood pressure, right will be tre-

Formulation of diagnoses for certain diseases of the cardiovascular system

ty variant of the diagnosis 5. The case is coded I 15.2 as hypertension secondary to endocrine disorders, in this case, diabetes mellitus with kidney damage.

The first option is erroneous, since when formulating a clinical diagnosis, the emphasis is not on a specific condition that was the main reason for treatment and examination, but on the etiology of the syndrome, which in this case has a relatively formal meaning. As a result, the code will be included in the statistics EY. The second option, on the contrary, does not take into account the etiology of hypertension at all, and therefore is also incorrect.

^ 2.5. ISCHEMIC HEART DISEASES

The term "ischemic heart disease" is a group concept.

ICD code: I20-I25

I20 Angina pectoris (angina pectoris)

I20.0 Unstable angina

Our Blog

Examples of formulations of the diagnosis of arterial hypertension

- Hypertension stage II. Degree of hypertension 3. Dyslipidemia.

- Left ventricular hypertrophy. Risk 4 (very high).

- Hypertension stage III. Degree of arterial hypertension 2. IHD. Angina pectoris II FC. Risk 4 (very high).

V.S.Gasilin, P.S.Grigoriev, O.N.Mushkin, B.A.Blokhin. Clinical classifications of some internal diseases and examples of the formulation of diagnoses

OCR: Dmitry Rastorguev

Origin: http://ollo.norna.ru

MEDICAL CENTER FOR THE ADMINISTRATION OF THE PRESIDENT OF THE RUSSIAN FEDERATION

SCIENTIFIC CENTER POLYCLINIC No 2

CLINICAL CLASSIFICATIONS OF SOME INTERNAL DISEASES AND EXAMPLES OF DIAGNOSIS FORMULATION

Reviewer: Head of the Department of Therapy, Moscow Medical Stomatological Institute. N. D. Semashko, Dr. med. Sciences. Professor V. S. ZODIONCHENKO.

I. DISEASES OF THE CARDIOVASCULAR SYSTEM

1. Classification of arterial hypertension (AH)

1. According to the level of blood pressure (BP)

1.1. Normal BP - below 140/90 mm rt st

1.2. Borderline blood pressure - 140-159 / 90-94 mm from art. 1.3_Argerial hypertension - 160/95 mm rt. Art. and higher.

2. By etiology.

2.1. Essential or primary hypertension (hypertension - GB).

2.2. Symptomatic arterial hypertension

Renal: acute and chronic glomerulonephritis; chronic pyelonephritis; interstitial nephritis with gout, hypercalcemia; diabetic glomeruloskerosis; polycystic kidney disease; nodular periarteritis and other intrarenal arteritis; systemic lupus erythematosus; scleroderma; amyloid-wrinkled kidney; hypoplasia and congenital defects of the kidney; urolithiasis disease; obstructive uropathy; hydronephrosis; nephroptosis; hypernephroid cancer; plasmacytoma and some other neoplasms; traumatic perirenal hematoma and other kidney injuries.

Renovascular (vasorenal): fibromuscular dysplasia of the renal arteries; atrosclerosis of the renal arteries; nonspecific aortoarteritis; thrombosis and embolism of the renal arteries; compression of the renal arteries from the outside (tumors, adhesions, hematoma scars).

Endocrine: adrenal (primary aldostetonism, adenoma of the adrenal cortex, bilateral hyperplasia of the adrenal cortex, Itsenko-Cushing's disease and syndrome; congenital adrenal hyperplasia, pheochromocytoma); pituitary (acromegaly), thyroid (thyrotoxicosis), parathyroid (hyperparathyroidism), carcinoid syndrome.

Hemodynamic: atherosclerosis and other aortic seals; coarctation of the aorta; aortic valve insufficiency; complete atrioventricular block; arteriovenous fistulas: open ductus arteriosus, congenital and traumatic aneurysms, Paget's disease (osteitis deformans); congestive circulatory failure; erythremia.

Neurogenic: tumors, cysts, brain injuries; chronic ischemia of the brain with narrowing of the carotid and vertebral arteries; encephalitis; bulbar poliomyelitis.

Late toxicosis of pregnant women.

Exogenous: poisoning (lead, thallium, cadmium, etc.); medicinal effects (prednisolone and other glucocorticoids; mineralocorticoids); contraceptives; severe burns, etc.

Classification of essential hypertension (essential hypertension) (401-404)

By stages: I (functional).

II (cardiac hypertrophy, vascular changes). III (resistant to treatment).

With a primary lesion: heart, kidneys, brain, eyes.

Hypertonic disease

Stage I Signs of changes in the cardiovascular system caused by hypertension are usually not yet detected. DD at rest ranges from 95 to 104 mm Hg. Art. SD - within 160-179 mm Hg. Art. average hemodynamic from 110 to 124 mm Hg. Art. The pressure is labile. It changes noticeably throughout the day.

Stage II. It is characterized by a significant increase in the number of complaints of a cardiac and neurogenic nature. DD at rest fluctuates between 105-114 mm Hg. Art.; SD reaches 180-200 mm Hg. Art. average hemodynamic - 125-140 mm Hg. Art. The main distinguishing feature of the transition of the disease to this stage is left ventricular hypertrophy, usually diagnosed by a physical method (ECG, ECHOCG and X-ray); a clear II tone is heard over the aorta. Changes in the arteries of the fundus. Kidneys:

proteinuria.

Stage III. Severe organic lesions of various organs and systems, accompanied by certain functional disorders (circulatory failure of the left ventricular type, hemorrhage in the cortex, cerebellum or brain stem, retina, or hypertensive encephalopathy). Hypertensive retinopathy with significant changes in the fundus and decreased vision. Treatment-resistant hypertension: DD in the range of 115-129 mm Hg. Art. SD - 200-230 mm Hg. Art. and above, the average hemodynamic - 145-190 mm Hg. Art. With the development of severe complications (myocardial infarction, stroke, etc.), blood pressure, especially systolic, usually decreases significantly, and often to a normal level ("headless hypertension").

Examples of the formulation of the diagnosis

1. Hypertension I stage.

2. Hypertension stage II with a primary lesion of the heart.

Note: the classification of arterial hypertension takes into account the recommendations of the WHO expert committee.

2. Classification of neurocirculatory dystonia (NCD) (306)

Clinical types:

1. Hypertensive.

2. Hypotonic.

3. Cardiac.

According to the severity of the flow:

1. Mild degree - pain and tachycardia syndromes are moderately expressed (up to 100 beats per minute), occur only in connection with significant psycho-emotional and physical stress. There are no vascular crises. There is usually no need for drug therapy. Employability is preserved.

2. Medium degree - a heart attack is persistent. Tachycardia occurs spontaneously, reaching 110-120 beats per minute. Vascular crises are possible. Drug therapy is applied. Ability to work is reduced or temporarily lost.

3. Severe degree - pain syndrome is persistent Tachycardia reaches 130-150 beats. in min. Respiratory disturbances are expressed. Frequent vegetative-vascular crises. Often mental depression. Drug therapy is necessary in a hospital setting. Ability to work is sharply reduced and temporarily lost.

Note: vegetative-vascular dystonia (VVD) is characterized by a combination of autonomic disorders of the body and is indicated in a detailed clinical diagnosis after the underlying disease (pathology of internal organs, endocrine glands, nervous system, etc.), which may be an etiological factor in the occurrence of autonomic disorders .

Examples of the formulation of the diagnosis

1. Neurocirculatory dystonia of hypertonic type, of moderate severity.

2. Climax. Vegetative-vascular dystonia with rare sympathetic-adrenal crises.

3. Classification of coronary heart disease (CHD) (410-414,418)

Angina:

1. Angina pectoris:

1.1. First-time angina pectoris.

1.2. Stable exertional angina with an indication of the functional class of the patient from I to IV.

1.3. Angina pectoris progressive.

1.4. Spontaneous angina (vasospastic, special, variant, Prinzmetal).

2. Acute focal myocardial dystrophy.

3. Myocardial infarction:

3.1. Large-focal (transmural) - primary, repeated (date).

3.2. Small-focal - primary, repeated (date).

4. Postinfarction focal cardiosclerosis.

5. Violation of the heart rhythm (indicating the form).

6. Heart failure (indicating the form and stage).

7. Painless form of coronary artery disease.

8. Sudden coronary death.

Note: The classification of coronary heart disease takes into account the recommendations of the WHO expert committee.

Functional class of stable angina depending on the ability to perform physical activity

I class The patient tolerates normal physical activity well. Attacks of stenocardia occur only with high-intensity loads. UM - 600 kgm and above.

P class- angina attacks occur when walking on a flat place at a distance of more than 500 m, when climbing more than 1 floor. The likelihood of an angina attack increases when walking in cold weather, against the wind, with emotional arousal, or in the first hours after waking up. YuM - 450-600 kgm.

SH class severe limitation of normal physical activity. Attacks occur when walking at a normal pace on level ground at a distance of 100-500 m, when climbing to the 1st floor, rare attacks of rest angina may occur. YuM - 300-450 kgm.

IV class- angina pectoris occurs with small physical exertion, when walking on a flat place at a distance of less than 100 m. The occurrence of angina attacks at rest is typical. YuM - 150 kgm or not carried out.

Note: The classification of the functional classes of stable angina pectoris was compiled taking into account the recommendations of the Canadian Heart Association.

Sudden coronary death- death in the presence of witnesses occurred instantly or within 6 hours from the onset of a heart attack.

New onset angina pectoris- duration up to 1 month from the moment of appearance.

stable angina- Duration more than 1 month.

Progressive angina- an increase in the frequency, severity and duration of seizures in response to the usual load for this patient, a decrease in the effectiveness of nitroglycerin; ECG changes may appear.

Spontaneous (special) angina pectoris- attacks occur during mowing, more difficult to respond to nitroglycerin, can be combined with angina pectoris.

Postinfarction cardiosclerosis- is placed no earlier than 2 months after the onset of myocardial infarction.

Heart rhythm disorder(indicating the form, stage).

Heart failure(indicating the form, stage) - is placed after postinfarction cardiosclerosis.

Examples of the formulation of the diagnosis

1. IHD. First-time angina pectoris.

2. IHD. Angina pectoris and (or) rest, FC - IV, diffuse cardiosclerosis, ventricular extrasystole. But.

3. IHD. Vasospastic angina.

4. IHD. Transmural myocardial infarction in the region of the posterior wall of the left ventricle (date), cardiosclerosis, atrial fibrillation, tachysystolic form, HIIA.

5. IHD. Angina pectoris, FC-III, postinfarction cardiosclerosis (date), blockade of the left bundle branch block. NIIB.

4. Classification of myocarditis (422) (according to N. R. Paleev, 1991)

1. Infectious and infectious-toxic.

1.1. Viral (influenza, Coxsackie infection, poliomyelitis, etc.).

1.2. Bacterial (diphtheria, scarlet fever, tuberculosis, typhoid fever).

1.3. Spirochetosis (syphilis, leptospirosis, relapsing fever).

1.4. Rickettsial (typhus, fever 0).

1.6. Fungal (actinomycosis, candidiasis, coccidioidomycosis, aspergillosis).

2. Allergic (immune): idiopathic (Abramov-Fiedler type), medicinal, serum, nutritional, with systemic connective tissue diseases (systemic lupus erythematosus, scleroderma), with bronchial asthma, Lyell's syndrome, Goodpasture's syndrome, burns, transplantation.

3. Toxic-allergic: thyrotoxic, uremic, alcoholic.

Diagnosis example

1. Infectious-toxic post-influenza myocarditis.

5. Classification of myocardial dystrophy (429) (according to N. R. Paleev, 1991)

According to the etiological characteristics.

1. Anemic.

2. Endocrine and dysmetabolic.

3. Toxic.

4. Alcoholic.

5. Overvoltage.

6. Hereditary and family diseases (muscular dystrophy, Frederick's ataxia).

7. Alimentary.

8. With closed chest injuries, exposure to vibration, radiation, etc.).

Examples of the formulation of the diagnosis

1. Thyrotoxic myocardial dystrophy with outcome in cardiosclerosis, atrial fibrillation, Np B stage.

2. Climax. Myocardial dystrophy. Ventricular extrasystole.

3. Alcoholic myocardial dystrophy, atrial fibrillation, Hsh stage.

6. Classification of cardiomyopathies (425) (WHO, 1983)

1. Dilated (stagnant).

2. Hypertrophic.

3. Restrictive (constrictive)

Note: cardiomyopathy should include lesions of the heart muscle that are not inflammatory or sclerotic in nature (not associated with a rheumatic process, myocarditis, coronary artery disease, cor pulmonale, hypertension of the systemic or pulmonary circulation).

Diagnosis example

1. Dilated cardiomyopathy. Atrial fibrillation. NpB.

7. Classification of rhythm and conduction disorders (427)

1. Violations of the function of the sinus node.

1.1. Sinus tachycardia.

1.2. sinus bradycardia.

1.3. sinus arrhythmia.

1.4. Stopping the sinus node.

1.5. Migration of the supraventricular pacemaker.

1.6. Sick sinus syndrome.

2. Ectopic impulses and rhythms.

2.1. Rhythms from the a-y connection.

2.2. Idioventricular rhythm.

2.3. Extrasystole.

2.3.1. Sinus extrasystoles.

2.3.2. Atrial extrasystoles.

2.3.3. Extrasystoles from a-y connection.

2.3.4. Recurrent extrasystoles.

2.3.5. Extrasystoles from the bundle of His (stem).

2.3.6. Supraventricular extrasystoles with aberrant OK8 complex.

2.3.7. Blocked supraventricular extrasystoles.

2.3.8. Ventricular extrasystoles. 2.4. Ectopic tachycardia:

2.4.1. Atrial paroxysmal tachycardia.

2.4.2. Tachycardia from a-y connections with simultaneous excitation of the atria and ventricles or with previous excitation of the ventricles.

2.4.3. Right ventricular or left ventricular paroxysmal tachycardia.

3. Violations of impulse conduction (blockade).

3.1. Sinoatrial blockade (SA blockade).

3.1.1. Incomplete SA blockade with Wenckebach periods (II degree, type I).

3.1.2. Incomplete SA blockade without Wenckebach periods (II degree II type).

3.2. Deceleration of atrial conduction (incomplete atrial block):

3.2.1. Complete interatrial block.

3.3. Incomplete a-y blockade of the 1st degree (slowdown of a-y conduction).

3.4. a-y blockade of the II degree (Mobitz type I) with periods of Samoilov-va-Wenckebach.

3.5. a-y II-degree blockade (Mobitz type II).

3.6. Incomplete a-y blockade, advanced, high degree 2:1, 3:1.4:1.5:1.

3.7. Complete a-y blockade of the III degree.

3.8. Complete a-y blockade with migration of the pacemaker in the ventricles.

3.9. The Frederick Phenomenon.

3.10. Violation of intraventricular conduction.

3.11. Complete blockade of the right leg of the bundle of His.

3.12. Incomplete blockade of the right leg of the bundle of His.

5. Parasystole.

5.1. Ventricular bradycardia parasystole.

5.2. Parasystoles from the a-y junction.

5.3. Atrial parasystole.

6. Atrioventricular dissociations.

6.1. Incomplete a-y dissociation.

6.2. Complete a-y dissociation (isorhythmic).

7. Flutter and flicker (fibrillation) of the atria and ventricles.

7.1. Bradysystolic form of atrial fibrillation.

7.2. Normosystolic form of atrial fibrillation.

7.3. Tachysystolic form of atrial fibrillation.

7.4. Paroxysmal form of atrial fibrillation.

7.5. Flutter of the stomach.

7.6. Ventricular fibrillation.

7.7. Ventricular asystole.

Note: in the classification of rhythm and conduction disorders, WHO recommendations are taken into account.

8. Classification of infective endocarditis (IE) (421)

1. Acute septic endocarditis (arising as a complication of sepsis - surgical, gynecological, urological, cryptogenic, as well as a complication of injections, invasive diagnostic manipulations).

2. Subacute septic (infectious) endocarditis (due to the presence of an intracardiac or adjacent to the arterial foci of infection leading to recurrent septicemia, embolism.

3. Protracted septic endocarditis (caused by viridescent streptococcus or strains close to it, with the absence of purulent metastases, the prevalence of immunopathological manifestations)

Notes: depending on the previous state of the valve apparatus, all IE are divided into two groups:

- primary, arising on unchanged valves.

- secondary, occurring on altered valves. Cases of the disease lasting up to 2 months. refer to acute over this period - to subacute IE.

Clinical and Laboratory Criteria for Infective Endocarditis Activity

Hypertension phobia of the 1st degree ("mild"
AG); medium risk: smoker; plasma cholesterol
7.0 mmol/l.

Hypertensive disease of the 2nd degree
rennaya AG); high risk: hypertrophy of the left
ventricle, angiopathy of retinal vessels.

Hypertensive disease of the 3rd degree (severe
barking AH) very high risk: transient ischemic
chesky brain attacks; IHD, angina pectoris 3 f.cl.

Isolated systolic hypertension 2nd
degrees; high risk: left ventricular hypertrophy
ka, type 2 diabetes mellitus, compensated.

In the clinical diagnosis formula, it is desirable to include independent risk factors that the patient has.

The psychological status of the patient, the assessment of personality typology are important parameters that determine the construction of an individual rehabilitation program that is adequate to the patient's motivation system.

Social diagnosis determines the cost characteristics of intervention in the natural course of the disease.

Secondary arterial hypertension

Systolodiastolic arterial hypertension:

Coarctation of the aorta. Physique of patients -
athletic with weak lower limbs. Ying
intense pulsation of the carotid and subclavian arteries
riy, pulsation of the aorta in the jugular notch. BP on ru
kah 200/100 mm Hg. Art., on the legs is not determined. wto
swarm tone above the aorta sonorous, above the apex, on the OS
heart rate is heard rough systolic
cue noise. ECG: left jelly hypertrophy syndrome
daughter. On radiographs - the heart of the aortic con
figurations, extended and shifted to the right aor
ta, usury of the ribs. To clarify the location and expression
These coarctations require aortography. When under
vision for coarctation of the aorta (if the patient agrees
for surgery) consultation of a vascular
surgeon.

You can think of secondary arterial hypertension when:

The development of hypertension in young people (under 30) and
high hypertension in persons over 60 years of age;

Hypertension refractory to therapy;

High malignant hypertension;

Clinical signs that do not fit into the general
accepted criteria for hypertension.

Pheochromocytoma. Easier to Diag
nostics is an option when patients with an outcome
but normal blood pressure causes sympathetic-adrenal
crises with headache, shortness of breath, vomiting, tahikar
diarrhoea, abdominal pain, frequent urination
eat. The duration of the crisis is 10-30 minutes. During
crisis increases blood pressure to 300/150 mm Hg. Art., t ° body -
to febrile numbers, leukocytosis is determined up to
10-13x10 9 /l, the concentration of glucose in
blood. The second option is sympatho-adrenal Cree
PS against the background of constant arterial hypertension.

If pheochromocytoma or pheochromoblastoma is suspected, the patient should be referred to an endocrinologist. Ultrasound examination reveals an enlarged shadow of the adrenal gland. If the patient agrees to the operation, metastasis to the lungs, liver, brain, bones (if pheochromoblastoma is suspected) is excluded. If such signs are excluded, the treatment is surgical.

Hypercortisolism diagnosed on the basis
clinical signs - combinations of arterial
hypertension with specific obesity (lu
purplish-cyanotic face
cheeks, fat deposition on the neck, upper body
shcha, shoulders, stomach with thin shins and forearm
I). The skin is thinning. In the iliac regions,
thighs, in the armpits, atrophy stripes
red-violet color. Osteoporosis is not uncommon
dysfunction of the genital organs, diabetes
bet. Differentiation of the primary adrenal
forms of hypercortisolism (Itsenko-Cushing's syndrome)
and Itsenko-Cushing's disease (basophilic adenoma
pophysis) is carried out in endocrinological clinics

Hypertonic disease

Kah. To detect a pituitary tumor, radiographs of the Turkish saddle are taken. Identification of a tumor of the adrenal glands is possible with ultrasound, scintigraphy, computed tomography. The method of treatment is chosen by a specialist.

Pubertal youthful dispituitarism
(hypothalamic syndrome of puberty).
Criteria: tall stature, obesity Cushingoid-
type, premature physical and sexual
whirling, pink striae, menstrual disorders
functions, gynecomastia, blood pressure lability with slope
increasing to borderline figures, vegeta
active crises.

Primary hyperaldosteronism(syndrome
Kona). Characteristic combination of arterial hypertension
zii with muscle weakness, sometimes reaching
degree of paralysis of the lower extremities, para-
sthesia, convulsions, polyuria, polydipsia, nick-
turia. Screening methods are research
blood electrolytes (hypokalemia, hyper-
natremia, hyperkaliuria). Ultrasound
Doing reveals an increase in the shadow of the adrenal gland.
Clarification of the diagnosis and determination of tactics is a task
endocrinologist.

Renovascular hypertension characterizes
with high numbers of diastolic blood pressure in patients
ent under 40 when renal artery stenosis
due to fibromuscular dysplasia,
lykh - stenosing atherosclerosis of the renal arteries
terium. Auscultation of the abdominal aorta and
its branches. Look for high frequency
noise in the epigastrium 2-3 cm above the navel, as well as on
this level to the right and left of the median line
vota.

Clarification of the diagnosis is carried out in specialized surgical clinics. Aortorenography has the highest resolution.

Hypernephroma in a typical way
characterized by macro- and microhematuria, fever,
general weakness, an increase in ESR to high numbers,
erythrocytosis, arterial hypertension, palpi
rummable kidney. To clarify the diagnosis, use
ultrasound methods, intravenous and ret
rograde pyelography, renal angiography. Pe
before referring a patient for consultation and
treatment by an oncologist, it is necessary to make sure of
the absence of metastasis. The most frequent loka
metastasis lysis - spine, lungs, liver,
brain.

Chronic pyelonephritis. For pyelonephritis
it is characterized by asthenic syndrome, aching pains
in the lower back, polyuria, nocturia, pollakiuria. Not by
lost its diagnostic value, the Almeida test
Nechiporenko (healthy urine contains no more
more than 1.5x10 b / l of erythrocytes, 3.0x10 6 / l of leukocytes).
Sternheimer-Melbin test ("pale leukocytes
you" in the urine) is positive not only with
pyelonephritis, as a change in morphology

leukocytes is not caused by the inflammatory process itself, but by the low osmolarity of urine. Great importance should be attached to a persistent search for bacteriuria. The amount of bacteriuria exceeding 100 thousand bacteria in 1 ml of urine is considered pathological. One- or two-sided nature of the lesion is verified using intravenous pyelography (deformation of the calyx, expansion of the pelvis, narrowing of the necks). The same method, as well as ultrasound examination of the kidneys, helps to diagnose nephrolithiasis, kidney anomalies, etc., which makes it possible to verify the secondary pyelonephritis. The method of isotope renography retains some value for clarifying the one- or two-sidedness of the lesion. Arterial hypertension in pyelonephritis is not necessarily due to the latter; both diseases are very common in the population, often combined. It is possible to directly “tie” hypertension to pyelonephritis when hypertension is synchronized with a pyelonephritically wrinkled kidney.

Chronic diffuse glomerulonephritis.
The existence of a "hypertonic" form of this
suffering is disputed (E.M. Tareev). More often it is
pertonia with low proteinuria
ki - target organ). arterial hypertension in
chronic glomerulonephritis usually "goes hand
hand in hand with chronic renal failure,
secondarily shriveled kidney.

Diabetic glomerulosclerosis. Characteristics
caused by proteinuria, cylindruria, arterial
hypertension. When combined with diabetes mellitus
listed symptoms of diagnostic difficulties
denial usually does not occur. Often there is a
even pathology: diabetes mellitus + hypertension
medical disease, diabetes mellitus + renovascular
hypertension, diabetes mellitus with glomerulo sclerosis
+ chronic pyelonephritis. The interpretation of pathology in
these cases is largely determined by carefully
carefully collected anamnesis of the disease, scrupulously
well-done physical examination,
screening methods (urinary sediment, ultra
sound examination of the kidneys, etc.).

Preeclampsia. Arterial hypertension in pregnancy
nyh may be a symptom of previous hyper
tonic disease, chronic glomerulonephritis
and chronic pyelonephritis. About gestosis follows
speak in cases where it is premorbidly neo-
burdened background in the 2nd-3rd trimesters appear
hypertensive, edematous, urinary syndromes. Ta
some cases of difficulties in the differential diagnosis
tic with hypertension is usually not
put.

Erythremia. Headaches, dizziness,
tinnitus, blurred vision, heart pain
tsa, "plethoric" appearance. Elevated blood pressure
in an elderly man with a red-bluish face,
an expanded vascular network on the nose, cheeks, with
overweight it is tempting to regard it as

Ambulatory cardiology

Sign of hypertension. This diagnosis seems to be even more reliable with the appearance of cerebral vascular crises, repeated strokes. It is possible to avoid a diagnostic error after a minimum additional examination. With erythremia, the number of erythrocytes is increased, hemoglobin is high, ESR is slowed down, the number of leukocytes and platelets in 1 liter of blood is increased.

Isolated systolic arterial hypertension

Atherosclerosis of the aorta characteristic of the elderly.
Clinical symptoms are determined by atherosclerosis
rotic lesion of the main vessels of the
fishing (headaches, mnestic disturbances and
etc.). Characterized by an accent and a change in the timbre of the 2nd
tones in the projection of the aorta, "compaction" of the shadow of the aorta,
according to x-ray data.

Aortic valve insufficiency, differential
fuzzy toxic goiter with phenomena expressed
thyrotoxicosis have a typical clinical
mud.

For arteriovenous aneurysms characteristic of
relevant history.

Bradyarrhythmias, severe bradycardia lu
bogo genesis often proceed with high isolated
systolic hypertension due to
large systolic output. diastolic
BP is usually low due to the vasodilation reflex with
aortic and carotid reflex zones.

Syndrome of malignant arterial hypertension

According to G.G. Arabidze, is diagnosed on the basis of defining criteria. These include high blood pressure (220/130 mm Hg and above), severe fundus lesions such as neuroretinopathy, hemorrhages and exudates in the retina; organic changes in the kidneys, quite often combined with functional insufficiency. The syndrome of malignant hypertension is often based on a combination of two or more diseases; renovascular hypertension and chronic pyelonephritis or glomerulonephritis, pheochromocytoma and chronic glomerulonephritis, chronic glomerulo-and pyelonephritis, chronic glomerulonephritis and diabetic nephropathy. Diagnosis of these combinations of diseases is possible with a thorough history taking, a detailed laboratory study (urine sediment, bacteriuria, etc.), ultrasound, X-ray, angiography. In some cases, verification of the nature of parenchymal kidney damage is possible after a puncture biopsy.

Patient management

Purpose of treatment: warning or vice versa

development of target organ damage, premature death due to cerebral stroke, myocardial infarction, preservation of the patient's quality of life. Tasks:

Relief of emergency conditions;

Creation in the patient of a system of motivations for you
completion of treatment programs (adequate
formation, inclusion of recommendations in the scale
patient's values)

Development and implementation of non-drug measures
foot impact;

Development and implementation of drug methods
Noah therapy.

Treatment standards:

scientific validity;

feasibility;

Blood pressure drops to numbers not lower than 125/85 mm Hg. Art.
to avoid a decrease in coronary and cerebral
perfusion.

Crises of hypertension

Hypertensive crisis - a state of sudden individually significant increase in blood pressure, accompanied by the appearance or aggravation of previously existing vegetative, cerebral, cardiac symptoms (V.P. Pomerantsev; N.N. Kryukov).

Classification.By pathogenesis: neurovegetative, water-salt, encephalopathic. By localization: cerebral, cardiac, generalized. By type of hemodynamics: hyper-, eu-, hypokinetic. By gravity: light, medium, heavy.

In a neurovegetative crisis, di-
encephalo-vegetative symptoms. Start outside
zapnoe, without precursors, the clinic characterizes
intense, throbbing headache
dizziness, flashing "flies" before the eyes
mi, pain in the heart, palpitations, dro
zhu, a feeling of cold hands and feet, sometimes without
pure fear. Pulse tense, rapid.
BP is sharply increased, more due to systole numbers
cal. Heart sounds are loud, accent of the second tone
on the aorta. The duration of the crisis is 3-6 hours.

Water-salt crises are more common in women
patients with stable hypertension develop according to
constantly, flow with complaints of heaviness in the head,
dull headache, ringing in the ears, blurred vision
niya and hearing, sometimes nausea and vomiting. Patients are pale

Hypertonic disease

We are lethargic and apathetic. The pulse is often slower. The figures of diastole and blood pressure were increased mainly. This type of crisis is usually preceded by a decrease in diuresis, the appearance of pastosity of the face and hands. The duration of the crisis is up to 5-6 days.

Encephalopathic variant of the crisis meeting
is used in hypertensive patients with syndrom
rum of malignant hypertension, proceeds with
loss of consciousness, tonic and clonic
roads, focal neurological symptoms
in the form of paresthesia, weakness in the distal parts
limbs, transient hemiparesis, disorders
vision, memory disorders. With prolonged flow
such crises, patients develop cerebral edema, pa
renchymatous or subarachnoid hemorrhage
nie, cerebral coma, and in some cases - a sharp
decreased diuresis, creatininemia, uremia.

Many patients with hypertensive crisis
disease, it is not possible to identify clear criteria for it
r about the vegetative or water-salt crisis. Then
should be limited to the assessment of predominantly
th clinical syndrome: cerebral with angios-
pastic disorders and/or cardio-
go. Evaluation of the severity of these symptoms
gives grounds for attributing a hypertensive crisis
which disease in a particular patient to cerebral
mu, cardiac, generalized (mixed).

Judgment on the type of hemodynamic disturbances is made according to the data of echocardiography, tetrapolar rheography.

Criteria for the severity of the crisis are determined by the severity of symptoms, its reversibility, and the timing of relief. In primary health care, it is critical to immediately assess the severity of the crisis. For express diagnostics suitable division of crises into two types according to R. Fergusson (1991):

Crises of the 1st type carry the risk of a life-threatening
target organ damage: encephalopia
tiya with a sharp headache, decreased vision
nia, convulsions; destabilization of angina pectoris,
acute left ventricular heart failure
accuracy, life-threatening arrhythmias; oligu-
ria, transient hypercreatininemia.

Crises of the 2nd type do not carry the risk of life
dangerous damage to target organs: heads
pain, dizziness without visual impairment
nia, seizures, cerebral neurological
symptoms; cardialgia, moderate
feminine dyspnea.

Isolation of two types of crises helps the doctor in choosing the tactics of managing the patient: urgently, within 30-60 minutes, reduce blood pressure in a crisis of type 1 or provide emergency care in a crisis of type 2 (reduce blood pressure within 4-12 hours).

V structure of clinical diagnosis A crisis of hypertension takes the place of a complication of the underlying disease:

disease of the 1st degree, mild arterial hyper-

tension. Complication. Hypertensive crisis (date, hour), neurovegetative, mild course.

underlying disease. Hypertensive bo
disease of the 2nd degree, moderate arterial
gi
crisis (date, hour), cerebral, middle
tin.

underlying disease. Hypertensive bo
disease of the 3rd degree, high arterial gi
pertension. Complication. Hypertensive
crisis (date, hour), encephalopathic, severe
slow flow.

underlying disease. Hypertensive bo
disease of the 2nd degree, high arterial gi
pertension. Complication. Hypertensive
type 1 crisis according to Ferguson (date, hour,
min), acute left ventricular failure
ness.

Management of the patient with hypertensive crises

Indications for the implementation of an emergency BP reduction program in type 1 crisis according to Fergusson(M.S. Kushakovsky): hypertensive encephalopathy, cerebral strokes, dissecting aortic aneurysm, acute heart failure, myocardial infarction and preinfarction syndrome, pheochromocytoma crisis, clonidine withdrawal crisis, diabetes mellitus crisis with severe angioretinopathy; pressure decreases within 1 hour by 25-30% of the original, usually not lower than 160/110-100 mm Hg. Art.

The effect of rapid controlled peripheral vasodilation is provided by intravenous drip infusion of sodium nitroprusside at a dose of 30-50 mg in 250-500 ml of 5% glucose solution; intravenous administration of a bolus of diazoxide at a dose of 100-300 mg; intravenous drip of arfon-da at a dose of 250 mg per 250 ml of isotonic sodium chloride solution; intravenous slow introduction of 0.3-0.5-0.75 ml of 5% pentamin solution in 20 ml of 5% glucose solution. Prolongation of the hypotensive effect is achieved by intravenous or intramuscular administration of 40-80 mg of furosemide.

Fergusson Type 2 Crisis Medium Intensity Program is designed to reduce blood pressure within 4-8 hours. It is used in most patients with cerebral, cardiac, generalized crises in stage 2 hypertension. Blood pressure should be reduced by 25-30% of the initial level. Orally drugs: nitroglycerin under the tongue at a dose of 0.5 mg, clonidine under the tongue at a dose of 0.15 mg, corinfar under the tongue at an initial dose of 10-20 mg. If necessary, clonidine or corinfar in the same dose can be administered every hour until the blood pressure decreases. Sublingual nitroglycerin, if necessary, again after 10-15 minutes. Furosemide 40 mg orally with hot water.

Ambulatory cardiology

You can use captopril at a dose of 25 mg, obzi-dan at a dose of 40 mg under the tongue, nitroglycerin tablets under the tongue.

Parenteral administration of drugs is indicated in more severe cases. Intravenous slow administration of 1-2 ml of a 0.01% solution of clonidine in 20 ml of isotonic sodium chloride solution is used; rausedil at a dose of 0.5-2 mg of a 1% solution intramuscularly; 6-12 ml of a 0.5% solution of dibazol intravenously in pure form or in combination with 20-100 mg of furosemide.

With clear criteria neurovegetative crisis in the treatment adrenolytic drugs of central action, neuroleptics, antispasmodics are used. The following options for stopping such a crisis are possible: intravenous or intramuscular injection of 1 ml of a 0.01% solution of clonidine; intramuscular injection of 1 ml of a 0.1% solution of rausedil (not used in previous treatment with β-blockers due to the risk of developing bradycardia, hypotension); intramuscular injection of 1-1.5 ml of droperidol, which not only lowers blood pressure, but also relieves symptoms that are painful for the patient (chills, trembling, fear, nausea); combined administration of dibazol and droperidol. Droperidol can be replaced with pyrroxane (1-2 ml of a 1.5% solution), Relanium (2-4 ml of a 0.05% solution).

Basic drugs in the treatment water-salt crisis are fast-acting diuretics, adrenolytic agents. Furosemide is injected into a vein or muscle at a dose of 40-80 mg, if necessary, in combination with intravenous administration of 1-1.5 ml of a 0.01% solution of clonidine or 3-5 ml of a 1% dibazol solution in isotonic sodium chloride solution. With persistent headaches, workload, decreased vision, 10 ml of a 25% solution of magnesium sulfate is injected intramuscularly.

If a hypertensive crisis associated with arrhythmias or proceeds against the background of angina pectoris, it is preferable to start treatment with intravenous administration of obzidan at a dose of 1-2-5 mg in 15-20 ml of isotonic sodium chloride solution. With tachycardia, treatment begins with intravenous or intramuscular administration of rausedil.

Features of the treatment of crises in the elderly. The tactics of rapidly lowering blood pressure is rarely used, mainly in acute left ventricular failure, if there are no anamnestic indications of myocardial infarction and cerebral stroke. After the introduction of antihypertensive drugs, it is necessary to observe bed rest for 2-3 hours. If there is a threat of developing pulmonary edema, antihypertensive drugs are combined with droperidol, furosemide. If the crisis proceeds without complications, you can get by with a slow injection of 6-12 ml of a 0.5% dibazol solution into a vein. With tachycardia, arousal, the elderly need to inject rausedil into a vein or muscle. Crises of hypertension in the elderly are often combined

with transient disorders of cerebral circulation (vertebrobasilar, carotid syndromes). In such cases, Cavinton is injected into a vein at a dose of 2 mg (4 ml) in 250-300 ml of isotonic sodium chloride solution. Slow intravenous administration of aminophylline in combination with cardiac glycosides is acceptable. No-shpa, papaverine hydrochloride cause a “stealing phenomenon” in ischemic areas of the brain, so their administration in case of cerebral circulation disorders is contraindicated.

Indications for urgent hospitalization(M.S. Kushakovsky): severe crisis and little effect of pharmacological agents used by the doctor; repeated increase in blood pressure a short time after the relief of the crisis; acute left ventricular insufficiency; destabilization of angina pectoris; the occurrence of arrhythmias and heart block; symptoms of encephalopathy.

I bought the crisis recurrence must be prevented. If the previous treatment was effective, it should be resumed; if not, a new treatment option should be selected.

Average periods of temporary disability with a neurovegetative variant of a crisis - 5-7 days, with a water-salt variant - 9-12 days, with an encephalopathic variant - up to 18-21 days. With a cardiac, cerebral, generalized crisis with a mild course, the ability to work is restored in 3-7 days, with a moderate one - in 7-9 days, with a severe one - 9-16 days.

Prevention of crises of hypertension. There are patients who develop crises as a result of traumatic situations, meteotropism, hormonal imbalance during menopause. Crises in these patients become significantly more rare after the appointment of small tranquilizers, sedatives. It is better not to prescribe antipsychotics for elderly patients without direct indications (E.V. Erina). Along with sedative therapy, drugs of metabolic action (aminalon, nootropics) are used. Tranquilizers are prescribed in cycles of 1.5-2 months, sedatives such as Quater's medicine, ankylosing spondylitis, valerian decoction, motherwort - for the next 3-4 months. Metabolic drugs are prescribed in cycles of 1.5-2 months. with breaks for 2-3 weeks.

For the prevention of crises associated with bruising; In case of premenstrual tension or arising during the period of pathological menopause, it is advisable to use antialdosterone drugs and diuretics. 3-4 days before the predicted deterioration of the condition, veroshpiron is prescribed for 4-6 days at a dose of 25-50 mg 3 times a day. Such treatment is carried out monthly for 1-2 years. A good effect can be obtained by prescribing potassium-sparing diuretics such as triampura by the same method, but once in the morning (Table 1-2).

In another group of patients, crises develop as a reaction to transient cerebral ischemia in chronic

Hypertonic disease

Nic vascular cerebral insufficiency of atherosclerotic origin, with an overdose of antihypertensive drugs, orthostatic hypotension. E.V. Erina managed to achieve a decrease in crises in such patients by prescribing caffeine, cordiamine, adonizide or lantozid in the first half of the day. With this treatment, orthostatic hypotension in the morning decreased, large fluctuations in systemic blood pressure, which are undesirable in cerebral atherosclerosis, were eliminated.

Organization of treatment

Indications for emergency hospitalization in the cardiology department. Syndrome of malignant arterial hypertension with complications (acute left-sided spectacle failure, intraocular hemorrhages, cerebral strokes). Life-threatening complications of hypertension of the 3rd degree. Hypertensive crises of the 1st type according to Ferguson.

Indications for planned hospitalization. One-time hospitalization to exclude secondary arterial hypertension (diagnostic studies that are impossible or impractical to conduct in a polyclinic). Hypertension with a crisis course, frequent exacerbations for the selection of adequate therapy.

Most hypertensive patients begin and end their treatment in the clinic.

Planned therapy

Information for the patient and his family:

Hypertension is a disease
a new symptom of which is an increase in ar
pressure and the resulting time
brain, heart, kidneys. Normal arterial
pressure not higher than 140/90 mm Hg. Art.

Only half of the people with elevated arte
real pressure know that they are sick, and of them
Not all are treated systematically.

Untreated hypertension is dangerous
complications, the main of which is cerebral infarction
sult and myocardial infarction.

Patient's personality traits: irritation
vehemence, irascibility, stubbornness, "excessive
independence" - rejection of the advice of others
day, incl. and doctors. The patient must be aware of
the weaknesses of your personality, treat them as kriti
Chesky, take the doctor's recommendations for execution.

The patient should be aware of the available
and members of his family risk factors for hypertension
and ischemic disease. It's smoking, excess
body weight, psycho-emotional stress, low
high lifestyle, elevated cholesterol levels
terina. These risk factors can be reduced with
the help of a doctor.

Especially important is the correction of changing factors
risk factors if the patient and his members have

10. Denisov

families of such factors as cerebral strokes, myocardial infarctions, diabetes mellitus (insulin-dependent); male gender; advanced age, physiological or surgical (postoperative) menopause in women.

Correction of risk factors is needed not only
already suffering from hypertension, but also a member
us families. These are family primary programs.
phylaxis and education, compiled by a doctor.

You need to know some indicators of the norm, to which
who should strive to:

Body weight according to the Kettle index:

body weight in kg

(height in m) 2

in the norm 24-26 kg/m 2 , overweight is considered with an index;> 29 kg/m 2 ;

Plasma cholesterol level: desired
<200 мг/дл (<5,17 ммоль/л), пограничный
200-240 mg/dL (5.17-6.18 mmol/L), elevated
ny >240 mg/dL (>6.21 mmol/L);

Low lipoprotein cholesterol level
which density, respectively<130 мг/дл
(<3,36 ммоль/л); 130-160 мг/дл (3,36-
4.11 mmol/l); >160 mg/dL (>4.13 mmol/L);

The level of glucose in the blood is not higher than 5.6
mmol/l;

The level of uric acid in the blood is not higher
0.24 mmol/l.

Tips for the patient and his family:

Sufficient sleep is considered at least 7-8 hours / day;
Your individual rate may be more, up to
9-10 o'clock

Body weight should be close to ideal
Noah. To do this, the daily calorie content of food should
on, depending on body weight and nature of work
you, range from 1500 to 2000 cal. Consumption
protein - 1 g / kg of body weight per day, carbohydrates - up to 50 g / day,
fat - up to 80 g / day. It is advisable to keep a diary
niya. The patient is strongly advised to avoid
gat fatty, sweet dishes, give preference
vegetables, fruits, cereals and wholemeal bread
grinding.

Salt intake should be limited - 5-7 g / day.
Don't salt your food. Replace salt with other
substances that improve the taste of food (sauces, small
some amount of pepper, vinegar, etc.).

Increase your potassium intake (there is a lot of it in the world)
live fruits, vegetables, dried apricots, baked potatoes).
The KVNa + ratio shifts towards K + at
predominantly vegetarian diet.

Stop or limit smoking

Limit alcohol consumption - 30 ml / day
in terms of absolute ethanol. Strong alcohol
nye drinks are better to replace red dry
wines with anti-atherosclerotic
activity. Permissible doses of alcohol per day
ki: 720 ml beer, 300 ml wine, 60 ml whiskey. Wives
chin dose is 2 times less.

Ambulatory cardiology

With hypodynamia (sedentary work 5 hours / day,
physical activity slO h/week) - regular fi
physical training at least 4 times a week. lengthwise
30-45 min. Preferred indie
loads that are visually acceptable for the patient:
walking, tennis, cycling, walking
skiing, gardening. During physical exertion
lo heart rate should not increase
more than 20-30 in 1 min.

Psycho-emotional stress at work
and in everyday life is controlled by the right way of life
neither. Work hours should be limited
day and home stresses, avoid night shifts,
business trips.

Autogenic training is carried out three times a day in one of the poses:

"coachman on a droshky" - sitting on a chair, push
kneeling down, hands on hips, hands
say, the body is tilted forward, does not touch
Xia chair back, eyes closed;

Reclining in a chair, head on the headrest;

Lying on the couch. The posture is most comfortable before
going to sleep.

Breathing rhythmically, inhale through the nose, exhale through the mouth.

L.V. Shpak successfully tested two versions of texts for autogenic training. Session duration - 10-15 minutes.

Text for autogenic training relaxing type. All the muscles on the face relaxed, the soul is light, good, in the heart area it is pleasant, calm. I calmed down like a mirror surface of a lake.

All the nerve centers of the brain and spinal cord that control my heart are working steadily, the blood vessels have expanded evenly along their entire length, the blood pressure has dropped, and there is absolutely free circulation in my body. All the muscles of the body deeply relaxed, lengthened, became soft, my head was filled with a pleasant light light.

The internal stability of the work of my heart is steadily increasing, my will is becoming stronger, the endurance of my nervous system is increasing every day. I AM I believe that, despite the harmful effects of weather and climate, any troubles in the family and at work, I will maintain a steady rhythmic pulse and normal blood pressure. I don't doubt it at all. During all the future time that I can imagine, I will be healthy and strong. I have a strong will and a strong character, I have unlimited control over my behavior and heart function, so I will always maintain normal blood pressure.

Text for autogenic training of a stimulating type. Now I completely switch off from the outside world and focus on the life of my own body. The organism mobilizes all its forces for the exact execution of everything that I will say about myself. All blood vessels from the crown of the head to the fingers and toes are fully open along their entire length. There is absolutely free blood circulation in my head, my head is bright, light, like weightless, the brain cells are more and more filled with the energy of life. Every day, the brain more and more steadily controls the work of the heart and the level of blood pressure, so my health improves, I become a cheerful and cheerful person, I always have normal blood pressure and a regular rhythmic pulse. I believe that the internal stability of the nerve centers that control the work of the heart and blood vessels is many times stronger than the harmful influences of nature, climate and human dishonesty. Therefore, I go through all the hardships of life, resentment, insults, and I unshakably maintain normal blood pressure and excellent health. My heart pumps blood throughout my body and fills me with new life energy. The stability of the work of the heart is constantly increasing. My body mobilizes all its unlimited reserves to maintain a normal level of blood pressure.

When exiting the session, take a deep breath, sipping, long exhalation.

Smoking, alcohol abuse often
secondary to psycho-emotional di
family stress. With a systematic fight against distress
so the patient usually reduces the amount of smoking
smoked cigarettes consumes less alcohol. If
this did not happen, you should use the opportunity
psychotherapy, acupuncture. In the most
In severe cases, consultation with a narcologist is possible.

If there are teenagers in the family with risk factors
ka cardiovascular diseases (mass index
body >25, plasma cholesterol >220 mg/dl, triglycerides
readings >210 mg/dl, "high normal" BP figures, ne
listed non-pharmacological events
spread over them. This is an important family measure.
prevention of hypertension.

The patient and his family members must have
method of measuring blood pressure, be able to keep a blood pressure diary with
fixing numbers in the early morning hours, in the afternoon, in
black.

If the patient is receiving antihypertensive drugs
rata, he must be aware of the expected
effect, changes in well-being and quality of life
during therapy, possible side effects and
ways to eliminate them.

Hypertonic disease

Women with hypertension
New, you need to stop taking oral con
traceptives.

Young men involved in sports should not be evil
use nutritional supplements "to build up
niya muscle mass "and exclude the use of anabolic
cal steroids.

Pharmacotherapy for hypertension

Diuretics. They are considered first-line drugs in the treatment of patients with arterial hypertension. Diuretics remove Na + ions from the wall of arterioles, reduce its swelling, reduce the sensitivity of arterioles to pressor effects, increase the activity of the antihypertensive kinin-kallik-rhein system by increasing the synthesis of prostaglandins in the kidneys. When using diuretics, the volume of circulating blood and cardiac output decrease.

Adverse metabolic effects of diuretics: hypokalemia, hyperuricemia, impaired carbohydrate tolerance, increased blood levels of atherogenic lipoprotein fractions. Since the metabolic effects are dose-related, it is undesirable to prescribe hypothiazide daily at a dose exceeding 25 mg / day. Correction of probable hypokalemia with potassium preparations or the appointment of combinations of hypothiazide with triamterene (triampur) is necessary. To predict the hypotensive effect of hypothiazide, a test with furosemide (I.K. Shkhvatsabaya) is used. Daily for 3 days, 1-2 tablets are prescribed. furosemide (40-80 mg). If blood pressure decreased significantly with a moderate increase in diuresis, hypothiazide therapy is indicated, if diuresis increased by 1.5-2 times, and blood pressure decreased unreliably - the hypotensive effect of diuretics is unlikely, monotherapy with diuretics is hardly appropriate. It should be remembered that the full hypotensive effect of thiazide diuretics develops after 3 weeks.

If possible, hypothiazide should be preferred to the more expensive, but no less effective drug "indapamide" (arifon), which does not have adverse metabolic effects. The full hypotensive effect of this drug is observed after 3-4 weeks of use.

The main characteristics of diuretics used in outpatient practice are shown in Table 27.

Requirements for antihypertensive drugs:

Reducing mortality and morbidity in
role studies;

Improving the quality of life;

. effectiveness in monotherapy;

Minimum side effects;

The possibility of taking 1 time per day;

Lack of pseudo-tolerance due to
retention of Na + ions and water, increase the volume of
cellular fluid leading to hypertension;

Lack of effect of the 1st dose, the possibility of
boron dose over 2-3 days;

The effect of the action is mainly due to the reduction in
resistance rather than a decrease in cardio
ejection;

Cheapness.

β-blockers. The hypotensive effect is due to a decrease in cardiac output, inhibition of the reflex from baroreceptors, and a decrease in renin secretion.

The hypotensive effect of β-blockers develops gradually, over 3-4 weeks, is directly related to the dose selected individually.

β-blockers are contraindicated in heart block, bradycardia, broncho-obstructive diseases, severe heart failure, atherosclerosis of peripheral arteries.

Side effects: weakness, headaches, skin rashes, hypoglycemia, stool disorders, depression.

β-blockers should be discontinued gradually over 2 weeks to avoid withdrawal symptoms.

The most promising are β-selective blockers (atenolol), especially prolonged ones (such as betaxolol) and those with vasodilating properties (bisoprolol).

The main characteristics of β-blockers are given in table 27.

Blockers of a- and β-adrenergic receptors. The negative ino- and chronotropic effect is due to the blockade of β-adrenergic receptors, vasodilating α-adrenergic receptors. The pharmacological group is represented by two drugs: labetolol and proxodolol, promising for hypertension with crises, suitable for long-term therapy.

Drugs are contraindicated in heart blockade, severe heart failure. Side effects are few. The main characteristics of bivalent blockers - see table 27.

calcium antagonists. Preparations of the nifedipine group realize the hypotensive effect mainly through the mechanisms of arteriolodilatation.

Preparations of the verapamil group give hemodynamic effects similar to those of β-blockers.

Drugs of the diltiazem group combine the properties of nifedipine and verapamil derivatives. Characteristics of the main calcium antagonists are shown in Table 27.

Ambulatory cardiology