Yu.B. Belousov, E.A. Ushkalova

New American and European recommendations for the prevention and treatment of arterial hypertension (AH), published in the middle of this year, are being reviewed. The new classification of blood pressure contained in the American recommendations includes, unlike the previous one, a stage of “prehypertension” and 2 stages of hypertension itself. The recommendations contain instructions for prescribing certain classes of antihypertensive drugs to different categories of patients (depending on the stage of hypertension, the presence of concomitant diseases or risk factors). European recommendations retain the previous classification of hypertension (without the stage of “prehypertension”) and are characterized by greater flexibility in approaches to treatment than American ones. Their authors were guided by the principle that recommendations should be primarily educational in nature, and tried to avoid rigid criteria and standards. At the same time, they recognize the proven benefits of certain pharmacological classes for certain categories of patients.

In May-June 2003, new American (National Heart, Lung, and Blood Institute of the US National Institutes of Health, 7 report of the Joint National Committee on the Prevention, Definition, Evaluation and Treatment of High Blood Pressure - JNC 7) and European recommendations (European Society of Hypertension and European Society of Cardiology) for the prevention and treatment of arterial hypertension (HTN). The American recommendations are published in a short version. Publication of their full version is expected in the coming months. On the contrary, European experts proposed a detailed version of the recommendations, which was simultaneously reported at the 13th European meeting on hypertension in Milan and published in the May issue of the Journal of Hypertension. The recommendations of North American and European experts differ significantly from each other and in a number of basic provisions.

The main changes in the new American recommendations, compared to the previous ones (JNC 6), affect the classification of hypertension and approaches to its treatment. These changes are based primarily on the results of recent large randomized multicenter trials.

The new classification of hypertension includes, unlike the previous one, a stage of “prehypertension” and 2 stages of hypertension itself (Table 1). The category of “prehypertension” includes patients with systolic blood pressure (SBP) 120-139 mm Hg. or diastolic (DBP) – 80-89 mm Hg. Art.

The American recommendations attach great importance to optimizing lifestyle, which is indicated for persons with normal blood pressure, in the stage of “prehypertension” and at all stages of hypertension itself (Table 2). Medicines recommended for the treatment of stages 1 and 2 of hypertension itself and in the presence of concomitant diseases (risk factors) are presented in tables 2. 3.

The purpose of developing the European Guidelines was to update the 1999 WHO and International Society of Hypertension (ISH) recommendations. The need for their revision is explained primarily by the fact that they were developed as a whole for a world population that differs significantly in characteristics (genetic, economic, cultural, etc.). At the same time, the European population is a more homogeneous group, characterized by a high incidence of cardiovascular diseases, despite a high level of medical care, and at the same time a significant potential life expectancy.

European experts do not support the “prehypertension” stage introduced in the American recommendations. They retained the WHO/ITF classification (Table 4). Leading author of the European recommendations prof. Mancia believes that the concept of "prehypertension" is equivalent to the concept of "pre-disease" for a healthy person and can have negative psychological consequences for a person who is told by a doctor that he has a pathological condition, but should not receive any treatment. In addition, according to the JNC 7 criteria, the “prehypertension” stage unites a heterogeneous group of individuals requiring different management. For example, a patient with blood pressure 122/82 mm Hg. Art. without additional risk factors, in accordance with evidence-based medicine, does not require pharmacological agents, while a diabetic with a family history of hypertension should be prescribed drug therapy with a blood pressure equal to 120/80 mm Hg. Art.

According to European recommendations, SBP is up to 129 mm Hg. Art. and DBP up to 84 mm Hg. Art. are considered normal, and SBP is from 130 to 139 mm Hg. and DBP from 85 to 89 mm Hg. Art. – as “high normal”. Thus, an important aspect of the European recommendations is the provision that there is no single boundary separating normal blood pressure from elevated blood pressure, which means that there is no single indicator that determines the initiation of drug therapy. In addition, the European classification retains stage III hypertension.

European recommendations also feature greater flexibility in approaches to treatment. Their authors were guided by the principle that recommendations should be primarily educational in nature, and tried to avoid rigid criteria and standards.

Unlike JNC 7, the European recommendations are based not only on data from clinical studies and their meta-analyses, but also on many other sources of information. While recognizing the value of evidence-based randomized clinical trials, European experts believe they often suffer from a number of limitations, namely:

• high-risk patients are selected to participate;
• the degree of evidence for secondary endpoints is inadequate;
• The therapeutic regimens used differ from actual clinical practice.

In addition, controlled randomized trials in patients with hypertension usually last 4-5 years, whereas in real life a middle-aged hypertensive patient may be on drug therapy for 20-30 years. Thus, the data available to date do not allow us to evaluate the results of long-term treatment.

The authors of the European recommendations also tried to avoid rigid standards for the management of specific patients, who inevitably differ in personal, medical and cultural characteristics. Accordingly, the definition of high-normal BP includes values ​​that may be considered high (ie, hypertensive) in high-risk individuals or acceptable in lower-risk individuals.

If the patient's systolic and diastolic blood pressure numbers fall into different categories, the stage of hypertension is determined by the higher indicator. In elderly patients with isolated systolic hypertension, its stage is assessed based on SBP values, provided that DBP is below 90 mmHg. Art.

The main goal of hypertension treatment is to minimize the risk of cardiovascular morbidity and mortality, therefore an important place in the European recommendations belongs to the assessment of overall cardiovascular risk, which allows determining the prognosis for a particular patient (Table 5).

The most common cardiovascular risk factors used for stratification include:

1. Levels of systolic and diastolic blood pressure.
2. Age over 55 for men.
3. Age over 65 for women.
4. Smoking.
5. Dyslipidemia:
   • total cholesterol >6.0 mol/l (> 250 mg/dl) or;
   • low-density lipoprotein cholesterol >4.0 mmol/L (> 155 mg/dL) or;
   • high-density lipoprotein cholesterol: for men<1,0 ммоль/л (<40 мг/дл), для женщин <1,2 ммоль/л (<48 мг/дл).
6. Family history of early development of cardiovascular disease (men - less than 55 years, women - less than 65 years).
7. Abdominal obesity* (abdominal circumference ≥ 102 cm in men, 88 cm in women.
8. C-reactive protein** ≥ 1 mg/dl.

* Obesity is called abdominal in order to draw attention to an important symptom of metabolic syndrome. In general, excess weight may not be a problem, provided that fat is not stored in the abdominal area.

** C-reactive protein was added to the risk factors following evidence that it reliably predicted high-density lipoprotein cholesterol levels and was associated with metabolic syndrome.

Evidence from randomized clinical trials suggests that blood pressure should be maintained at or below 140/90 mmHg to prevent cardiovascular morbidity and mortality. Art. and in patients with diabetes mellitus – 130/80 mm Hg. Art. The level of SBP and DBP (Table 4), along with the level of general cardiovascular risk (Table 5), is classified in the European recommendations as the main factors on the basis of which the need to start pharmacotherapy is determined.

For persons with high normal blood pressure (SBP 130-139 mmHg or DBP 85-89 mmHg) it is recommended:

1. Assess risk factors, end organ damage (especially kidney), diabetes mellitus and associated clinical conditions.
2. • if the risk is very high, start drug therapy;
   • at moderate risk, monitor blood pressure;
   • if the risk is low, do not undertake any interventions.

Persons with stages I and II of hypertension (SBP 140-179 mm Hg or DBP 90-109 mm Hg) are recommended:

1. Assess other risk factors (end organ damage, diabetes mellitus and associated clinical conditions).
2. Take measures aimed at changing lifestyle and correcting other risk factors or diseases.
3. Stratify absolute risk:
   • if there is a very high/high risk, start drug therapy immediately;
   • at moderate risk - monitor blood pressure and other risk factors for 3 months or more (SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg - start drug therapy, SBP

US Department of Health and Human Services. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm.

Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 report. JAMA. 2003;289:3560-72.

Mancia G. Presentation of the ESH-ESC Guidelines for the management of arterial hypertension. Program and abstracts of the 13th European Meeting on Hypertension; June 13-17, 2003; Milan, Italy.

Committee. 2003 European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens. 2003;21;1011-1053. Available online at: http://www.eshonline.org/documents/2003_guidelines.pdf.

Guidelines Sub-Committee. 1999 World Health Organization – International Society of Hypertension guidelines for the management of hypertension. J Hypertens. 1999;17:51-183.

Giuseppe Mancia, MD, PhD, Discussions of the 2003 ESH/ESC Hypertension Guidelines. http://www.medscape.com.

The ALLHAT Officers and Co-ordinators for the ALLHAT Collaborative Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone. JAMA. 2000;283:1967-1975.

Filippenko N.G. Povetkin S.V. Pokrovsky M.V. and others. Efficacy and tolerability of Renipril GT in experiment and clinic // Farmateka. – 2002. – No. 7-8. – pp. 22-26.

Treatment of infective endocarditis. Diagnosis of arterial hypertension/hypertension. European recommendations.

There are few comparative data on the prevalence of hypertension and the temporal dynamics of blood pressure in different European countries. In general, the prevalence of hypertension ranges from 30–45% of the general population, with a sharp increase with aging. There also appears to be marked differences in mean BP values ​​across countries, with no significant

systemic trends in blood pressure changes over the past ten years.

Due to the difficulties in obtaining comparable results in different countries and at different times, it has been proposed to rely on some surrogate indicator of hypertension. Stroke is a good candidate for this indicator, as it is generally accepted that hypertension is the most important cause of stroke. A close relationship has been described between the prevalence of hypertension and mortality from stroke. Stroke incidence and mortality dynamics

from it in Europe were analyzed according to statistics from the World Health Organization (WHO). In Western countries, there is a downward trend in this indicator, in contrast to Eastern European countries, where mortality from stroke is clearly increasing.

For a long time, in the recommendations for hypertension, the only or main parameters determining the need and type of therapy were blood pressure values. In 1994, the ESC, ESH and the European Atherosclerosis Society (EAS) developed joint recommendations for the prevention of coronary heart disease (CHD) in clinical practice, which emphasized that the prevention of CHD should be carried out taking into account a quantitative assessment of the total (or total) cardiovascular risk. Currently, this approach is generally accepted and was already included in the ESH/ESC recommendations on hypertension from 2003 and 2007. This

the concept is based on the fact that only a small part of the population of people with hypertension has only increased blood pressure, while the majority also have other cardiovascular risk factors. Moreover, the simultaneous presence of elevated blood pressure and other cardiovascular risk factors may mutually reinforce each other, and together give a higher overall cardiovascular risk than the sum of its individual components. Finally, in individuals in the high-risk category, the tactics of antihypertensive therapy (initiation and intensity of treatment, use of drug combinations, etc., see sections 4, 5, 6 and 7), as well as other types of treatment, may differ from those in patients in the group low risk. There is evidence that in patients at high risk, it is more difficult to achieve blood pressure control, and they more often require antihypertensive drug therapy in combination with other drugs, for example, together with active lipid-lowering therapy. To maximize the cost-effectiveness of hypertension treatment, treatment approaches must consider not only BP levels, but also overall cardiovascular risk.

Because absolute overall cardiovascular risk is highly dependent on age, it may be low in younger patients even when high blood pressure is combined with other risk factors. However, if treated inadequately, this condition can transform years later into a partially irreversible high-risk condition. In young people, therapeutic decisions are best made based on quantitative estimates of relative risk or by determining “cardiac age” and “vascular age.”

The importance of diagnosing end-organ damage should be re-emphasized, since hypertension-associated asymptomatic changes in multiple organs indicate progression of the cardiovascular continuum, which greatly increases risk beyond that which depends on risk factors alone. The identification of asymptomatic target organ damage is the subject of a separate section, which discusses the evidence for the additional risk associated with each subclinical disorder. More than ten years in international recommendations for the treatment of hypertension (WHO, 1999; WHO/International Society of Hypertension, 2003; ESH/ESC recommendations

2003 and 2007) cardiovascular risk is divided into different categories based on blood pressure, the presence of cardiovascular risk factors, asymptomatic target organ damage, diabetes, clinically manifest cardiovascular disease and chronic kidney disease (CKD). The 2012 ESC prevention guidelines adhere to the same principle.

The classification of low, moderate, high and very high risk is retained in these guidelines and refers to the 10-year risk of cardiovascular mortality as defined in the ESC prevention guidelines. Assessment of general cardiovascular risk. In certain subgroups of patients, such as those with pre-existing cardiovascular disease, diabetes, coronary artery disease, or severe individual risk factors, assessing overall cardiovascular risk is straightforward.

In all of the mentioned conditions, the total cardiovascular risk is high or very high, which dictates the need for intensive measures to reduce it. However, a large number of patients with hypertension do not fall into any of the above categories. For this reason, to classify patients into groups of low, moderate, high or very high risk, it is necessary to use models to calculate the total cardiovascular risk.

vascular risk, which allows for appropriate adaptation of therapeutic approaches. Several computer methods have been developed to calculate total cardiovascular risk. A review of their significance and limitations has recently been published. The Systematic Coronary Risk Estimation (SCORE) model was developed from large European cohort studies. It allows you to calculate the risk of death from cardiovascular (not just coronary) diseases in the next 10 years based on age, gender, smoking, total cholesterol and SBP. Using the SCORE model, risk tables have been adapted for individual countries, in particular for many European countries. Two sets of tables have also been prepared for international use: one for high-risk countries, the second for low-risk countries.

Due to increasing life expectancy and the aging of the planet's population, arterial hypertension has acquired the status of an epidemic and a global problem for humanity. Studies of recent decades in cardiology have been devoted to this problem, studying the features of the course, its contribution to the formation of cardiovascular risk and mortality in the case of absence, untimely or inferior treatment. Due to the fact that arterial hypertension often begins at a young age and over time, in the absence of proper treatment, forms a cause-and-effect complex that leads to the formation of other cardiovascular diseases and aggravates the course of extracardiac nosologies.

Effect of hypertension on cardiovascular risk

Over the past decades, many clinical and epidemiological studies have been conducted in the field of treatment of arterial hypertension and the course of hypertension. The results obtained demonstrated the importance of the negative impact of hypertension on the risk of cardiovascular events, incl. leading to death due to fatal complications. It has been proven that arterial hypertension is directly related to an increase in the number of strokes and cases of coronary artery disease (coronary heart disease), incl. ending in death due to these diseases. Thus, about 67% of cases of strokes and more than 50% of confirmed diagnoses of coronary artery disease were caused and associated with arterial hypertension. Just think about these numbers. If there is no treatment for arterial hypertension, the disease kills 7 million people a year and also causes disability in 64 million patients! And, undoubtedly, the closest interdependence is observed between arterial hypertension and strokes - cardiovascular disasters that are virtually untreatable and most often lead to death.

Arterial hypertension and other diseases

The cause-and-effect relationship between hypertension and the risk of problems other than cardiovascular disease is less well understood. At the same time, there are frequent correlations of high blood pressure with diseases such as kidney dysfunction and diabetes mellitus. For example, treatment of arterial hypertension will not be sufficiently effective if the patient is diagnosed with diabetic nephropathy, therefore, in the dynamics, the pathological outcomes of these diseases always aggravate each other. If the above diseases occur against the background of hypertension, then they, in turn, serve as an additional risk factor, as a result of which arterial hypertension itself is aggravated. Such situations require an individual combined approach to treatment.

Hypertension severity and risk levels

What degree of severity arterial hypertension has and what treatment is necessary is determined depending on the patient’s blood pressure level, as well as the presence of concomitant unfavorable factors that aggravate the situation and complicate treatment (gender, age, excess weight, smoking, heredity, concomitant CVD, etc.) . According to the recommendations of international experts, in the absence of other cardiovascular risk factors, the target blood pressure level is<140/90 мм рт. ст. Ученые приводят доказательства того, что риск кардиоваскулярных событий и смертность значительно возрастают, начиная с цифр повышенного нормального давления.

Arterial hypertension is the root cause of many CVDs. Existing hypertension significantly worsens the prognosis for the health and life of the patient.

To assess the cumulative impact of several risk factors relative to the absolute risk of severe cardiovascular damage, WHO-IH experts proposed stratifying the risk into “low”, “moderate”, “high” and “very high”. In each category, the risk is calculated based on information on the average 10-year risk of non-fatal myocardial infarction and stroke, death from cardiovascular diseases according to the results of the Framingham Study.

Risk factors

Target organ damage (stage II HD, WHO 1993)

Concomitant (associated) clinical conditions (stage III HD, WHO 1993)

Basic:

• women over 65 years of age;
• men over 55 years old;
• men under 55 years of age and women under 65 years of age with a family history of early cardiovascular disease;
• smokers;
• people with cholesterol levels above 6.5 mmol/l;
• suffering from diabetes.

Additional* risk factors that negatively affect the treatment of a patient with hypertension:

• increased LDL cholesterol;
• microalbuminuria in diabetes;
• increased fibrinogen;
• decrease in HDL cholesterol;
• obesity;
• maintaining a sedentary lifestyle;
• socio-economic risk group.

Proteinuria and/or creatininemia 1.2-2.0 mg/dl. X-ray or ultrasound signs of atherosclerotic plaques. Focal or generalized narrowing of the retinal arteries. Left ventricular hypertrophy (ECG, echocardiography or radiography).

Heart diseases

Dissecting aortic aneurysm

peripheral arteries.

Hypertensive retinopathy

Exudates or hemorrhages.

Papilledema

Distribution of arterial hypertension (hypertension) by risk level - risk stratification in patients with hypertension

Karpov Yu.A. Starostin I.V.

Introduction

In June 2013 G. at the Annual European Conference on arterial hypertension(AG) were presented new recommendations according to her treatment. created by the European Society for hypertension(EOG, ESH) and the European Society of Cardiology (EOC, ESC). They are a continuation recommendations from 2003 and 2007 yy. updated and expanded in 2009 G. . These recommendations maintain continuity and commitment main principles: based on properly conducted studies found through a comprehensive analysis of the literature, take into account the priority of randomized controlled trials (RCTs) and meta-analyses of research data, as well as the results of observational and other studies of proper quality, class recommendations(Table 1) and level of evidence (Table 2). Recommendations were developed over 18 months. and before publication were reviewed twice by 42 European experts (21 from each Society).

Currently, the Russian Medical Society arterial hypertension(RMOAG), affiliated with the European Society of Hypertension, is preparing to publish a domestic version of these recommendations.

New aspects

1. New epidemiological data on hypertension and its control in European countries.

2. Recognition of the greater predictive value of home monitoring arterial pressure (DMAP) and its role in diagnosis and treatment AG.

3. New data on the impact on the prognosis of nighttime blood pressure, “white coat hypertension” and masked hypertension .

4. Assessment of overall cardiovascular risk - greater emphasis on blood pressure, cardiovascular risk factors, asymptomatic target organ damage and clinical complications.

5. New data on the impact of asymptomatic target organ damage, including the heart, blood vessels, kidneys, eyes and brain, on prognosis.

6. Clarification of the risk associated with excess body weight and the target value of body mass index (BMI) for hypertension.

7. Hypertension in young patients.

8. Start of antihypertensive therapy. Increasing the evidence of criteria and abstaining from drug therapy for high normal blood pressure.

9. Target values ​​for blood pressure therapy. Unified systolic target values arterial pressure (SBP) (<140 мм рт.ст.) у пациентов из группы как с высоким, так и с низким сердечно-сосудистым риском.

10. Free approach to initial monotherapy, without any ranking of drugs.

11. Modified scheme of preferred combinations of two drugs.

12. New treatment algorithms to achieve target blood pressure.

13. Added section on tactics treatment in special situations.

15. Drug therapy in persons over 80 years of age.

16. Particular attention to resistant hypertension, new approaches to its treatment.

17. Increased attention to therapy taking into account target organ damage.

18. New approaches to long-term (chronic) therapy of hypertension.

Further in the article the most important, from our point of view, will be reflected. changes compared to previous recommendations, which may be of interest to a wide range of doctors and scientists and will serve as a kind of “road map” for a more detailed study of the full version of the recommendations. You can find the full version of the recommendations on the official website of the Russian Medical Society for Hypertension - www.gipertonik.ru.

New epidemiological data on hypertension

One of the best surrogate indicators reflecting the situation with hypertension is stroke and mortality from it. In Western European countries there is a decrease in the incidence of strokes and mortality from them, while in Eastern European countries, incl. in Russia (WHO data from 1990 to 2006), mortality from stroke increased until recently and only in the last 3 years began to decrease.

Out-of-office blood pressure monitoring

Out-of-office BP monitoring refers to 24-hour BP monitoring (ABPM), carried out using a device continuously worn throughout the day, and home BP monitoring (HBP), in which a patient trained in the technique of measuring BP independently makes measurements. Out-of-office blood pressure measurement has a number of advantages, which is reflected in the new recommendations on hypertension from 2013 G. Basics of these - a larger number of measurements, which better reflects the real situation with blood pressure than measurements taken by a doctor. In addition, outpatient change BP correlates better than office BP with such markers of target organ damage in patients with hypertension, such as left ventricular hypertrophy (LVH), thickness of the intima-media complex of the carotid artery, etc., and ABPM correlates better with morbidity and mortality than office BP. Interestingly, the advantage of out-of-office blood pressure monitoring was identified both in the general population and in certain subgroups: in young and elderly patients, in people of both sexes, both on and without drug treatment, as well as in high-risk individuals, persons with cardiovascular diseases and kidney diseases. It has also been found that nighttime blood pressure is a stronger predictor than daytime blood pressure. The new guidelines emphasize that the clinical significance of the type changes night blood pressure (the so-called “dipping”) has not yet been fully determined, because Data on changes in cardiovascular risk in individuals with severe “dipping” are heterogeneous.

Currently, there are recommendations that should be followed for DMAD. Leaving aside the methodological issues of conducting DMAD, it should be noted that telemonitoring and applications for DMAD for smartphones are in use, and the interpretation of the results and correction of treatment should, of course, be carried out under the guidance of a physician. Unlike ABPM, ABPM allows you to assess changes in blood pressure over a long time and is associated with significantly lower costs, but does not allow you to assess night-time blood pressure values, differences in night and day blood pressure, as well as changes in blood pressure over short periods of time. It should be noted that ABPM is no worse than ABPM, correlates with target organ damage and has the same prognostic significance.

The choice of method for measuring out-of-office blood pressure (ABPM or DMBP) depends on the specific situation. Thus, during outpatient observation, it would be logical to use HMAD, while ABPM can be used in case of borderline or pathological HMAD results. Within the framework of specialized care, the use of ABPM seems more logical. In both cases, long-term monitoring of the effectiveness of treatment is impossible without DMAD. Clinical indications for out-of-office BP measurement are presented in Table 3.

Isolated office AG

(or "white coat hypertension")

and masked hypertension

(or isolated outpatient hypertension)

ABPM and DMAD are standard methods for identifying these nosological forms. Due to the inherent differences in these methods of measuring blood pressure, the definitions of “white coat hypertension” and “masked” hypertension";, diagnosed by ABPM and DMAD methods do not completely coincide. The subject of debate remains the question of whether individuals with “white coat hypertension” can be classified as true normotensives. Some studies have shown long-term cardiovascular risk in individuals with this condition to be intermediate between persistent hypertension and true normotension. However, according to meta-analyses that took into account gender, age and other confounding factors, the cardiovascular risk with “white coat hypertension” did not differ significantly from that with true normotension; however, this may be due to the treatment that some of these patients receive. The diagnosis of “white coat hypertension” is recommended to be confirmed no later than after 3-6 months. and carefully examine and monitor these patients.

Population-based studies estimate the prevalence of masked hypertension to be as high as 13% (range, 10 to 17%). Meta-analyses of prospective studies indicate a twofold increase in cardiovascular morbidity in this disease compared with normotension, which corresponds to persistent hypertension. A possible explanation for this phenomenon is the poor diagnosis of this condition and, accordingly, the lack of treatment in these patients.

Initiation of antihypertensive therapy

and target values

According to recommendations ESH/ESC 2007, antihypertensive therapy should be prescribed even to patients with stage 1 hypertension without other risk factors or target organ damage if drug therapy was unsuccessful. In addition, antihypertensive therapy was recommended for patients with diabetes, cardiovascular disease and CKD, even if their blood pressure is in the high normal range (130-139/85-89 mmHg).

Currently, there is very little evidence in favor of antihypertensive treatment of patients with stage 1 hypertension of low and intermediate risk - not a single study has been specifically devoted to these patients. However, a recently published Cochrane meta-analysis (2012-CD006742) found a trend towards a reduction in the incidence of stroke when treating patients with stage 1 hypertension, but due to the small number of patients, statistical significance was not achieved. At the same time, there are a number of arguments in favor of treating stage 1 hypertension even with a low and moderate level of risk, namely: increased risk with expectant management, incomplete effectiveness of therapy in reducing cardiovascular risk, a large number of safe drugs, the presence generics, which is accompanied by a good cost-benefit ratio.

Increase in systolic blood pressure above 140 mm Hg. while maintaining normal diastolic blood pressure (<90 мм рт.ст.) у молодых здоровых мужчин не всегда сопровождается повышением центрального АД . Известно, что изолированная систолическая гипертония у молодых не всегда переходит в систолическую/диастолическую АГ , а доказательств, что антигипертензивная терапия принесет пользу, не существует. Таким образом, этих больных следует тщательно наблюдать и рекомендовать изменение образа жизни.

The attitude towards prescribing antihypertensive therapy to patients with high and very high cardiovascular risk associated with diabetes, concomitant cardiovascular or renal diseases, with high normal blood pressure values ​​(130-139/85-89 mmHg) has also changed. The scant evidence on the advisability of such early medical intervention does not allow us to recommend the initiation of antihypertensive therapy in such patients.

Target blood pressure values ​​for most groups of patients are less than 140 mmHg. for systolic blood pressure and less than 90 mm Hg. - for diastolic. At the same time, elderly and senile hypertensive patients under 80 years of age with an initial SBP level of ≥160 mm Hg. It is recommended to reduce SBP to 140-150 mmHg. . At the same time, the satisfactory general health of this group of patients makes it potentially advisable to reduce SBP<140 мм рт.ст. а у пациентов с ослабленным состоянием здоровья следует выбирать целевые значения САД в зависимости от переносимости. У больных старше 80 лет с исходным САД ≥160 мм рт.ст. рекомендовано его снижение до 140-150 мм рт.ст. при условии, что они находятся в удовлетворительном физическом и психическом состоянии . Больным диабетом рекомендуется снижение ДАД до значений менее 85 мм рт.ст. .

At the moment, there are no randomized studies with clinical endpoints that would allow us to determine target blood pressure values ​​during home and ambulatory monitoring. However, according to some data, an effective reduction in office blood pressure is accompanied by not too large differences in out-of-office indicators. In other words, this study shows that the more pronounced the reduction in BP (as measured in the hospital) during antihypertensive therapy, the closer these values ​​​​are to the values ​​​​obtained during ambulatory monitoring, with the maximum similarity of results being achieved with office BP<120 мм рт.ст.

Choice of antihypertensive therapy

Same as in recommendations ESH/ESC 2003 and 2007 , the new recommendations retain the statement that there is no superiority of any class of antihypertensive drugs over others, because basic the benefits of antihypertensive therapy are due to the reduction in blood pressure itself. Therefore, new guidelines support the use of diuretics (including thiazide diuretics, chlorthalidone and indapamide), β-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers as initial and maintenance, mono- and combination therapy. Thus, there is no universal ranking of antihypertensive drugs due to the lack of preference.

The new recommendations retain the statement that it is advisable to start treatment with a combination of two drugs in patients at high risk or with very high initial blood pressure. This is because the combination of two antihypertensive drugs from different classes, as shown in a meta-analysis of more than 40 studies, leads to a greater reduction in blood pressure than increasing the dose of monotherapy. Combination therapy leads to a more rapid decrease in blood pressure in a larger number of patients, which is especially important for high-risk patients with very high blood pressure. In addition, patients receiving combination therapy refuse treatment less often than patients receiving monotherapy. We should not forget about the synergy between drugs of different classes, which can lead to less severe side effects. At the same time, combination therapy has a disadvantage, which is the potential ineffectiveness of one of the drugs in the combination, which is difficult to identify.

If monotherapy or a combination of two drugs is ineffective, it is recommended to increase the dose until the target blood pressure is achieved, up to the full dose. If the use of a combination of two drugs in full doses is not accompanied by the achievement of target blood pressure, a third drug can be added or the patient can be transferred to another combination therapy. It should be remembered that in case of treatment-resistant hypertension, the addition of each drug should occur with monitoring of the effect, in the absence of which the drug should be discontinued.

There are a significant number of randomized clinical trials examining antihypertensive treatment using combinations of antihypertensive drugs, but only three of them consistently used a specific combination of two antihypertensive drugs. In the ADVANCE trial, a combination of an ACE inhibitor with a diuretic or placebo was added to existing antihypertensive therapy. The FEVER study compared calcium antagonist and diuretic combination therapy with diuretic monotherapy plus placebo. The ACCOMPLISH trial compared a combination of an ACE inhibitor and a diuretic with the same ACE inhibitor and a calcium antagonist. In all other studies, treatment in all groups began with monotherapy, and only then some patients received an additional drug, and not always only one. And in the ALLHAT study of antihypertensive and lipid-lowering therapy, the investigator independently chose the second drug among those that were not used in the other therapeutic group.

However, almost all antihypertensive combinations were used in at least one treatment arm in placebo-controlled trials, with the exception of angiotensin receptor blockers and a calcium antagonist. In all cases, significant advantages were found in the active therapy groups. In addition, no significant differences were found when different combination therapy regimens were compared. As an exception, in two studies, the combination of an angiotensin receptor blocker and a diuretic and the combination of a calcium antagonist and an ACE inhibitor were superior to the combination of a beta blocker and a diuretic in reducing cardiovascular events. At the same time, in a number of other studies, the combination of a beta blocker with a diuretic was as effective as other combinations. The ACCOMPLISH study, a direct comparison of the two combinations, found significant superiority of an ACE inhibitor plus a calcium antagonist over an ACE inhibitor plus a diuretic, although blood pressure levels were identical. This may be due to the more effective effect of the calcium antagonist and RAAS inhibitor on central pressure. According to the ONTARGET and ALTITUDE studies, combining two different RAAS blockers is not recommended.

The new recommendations encourage the use of fixed-dose combinations of two or even three antihypertensive drugs in one tablet, because this leads to improved patient adherence to treatment, and therefore improves blood pressure control. The previously existing impossibility of changing the dose of one of the components independently of the other is gradually becoming a thing of the past, because More and more combinations with different doses of components are appearing.

Conclusion

In this article, we focused on only a small part of the changes that the recommendations on hypertension have undergone. However, reading this article will help form a first impression of the new recommendations and somewhat simplify familiarity with the full version, which is, of course, necessary for all specialists associated with the problem of hypertension.

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New recommendations on arterial hypertension RMOAG/VNOK 2010, issues of combination therapy

Karpov Yu.A.

Arterial hypertension(AH), being one of the main independent risk factors for the development of stroke and coronary heart disease (CHD), as well as cardiovascular complications - myocardial infarction (MI) and heart failure, is an extremely important health problem in most countries of the world. Successful control of such a common and dangerous disease requires a well-designed and organized detection and treatment program. This program has certainly become recommendations for hypertension, which regularly, as they appear new data are being revised. Since its release in 2008 G. third version of Russian recommendations on the prevention, diagnosis and treatment of hypertension were received new data requiring revision of this document. In this regard, on the initiative of the Russian Medical Society for Hypertension (RMAS) and the All-Russian Scientific Society of Cardiologists (VNOK), a new. the fourth version of this important document, which was discussed in detail in September 2010 G. presented at the annual VNOK Congress.

This document is based on recommendations on the treatment of hypertension of the European Society for arterial hypertension(EOG) and the European Society of Cardiology (ESC) 2007 and 2009 yy. and the results of major Russian studies on the problem of hypertension. Same as in previous versions recommendations. blood pressure is considered as one of the elements of the system for stratifying general (total) cardiovascular risk. When assessing overall cardiovascular risk, a large number of variables are taken into account, but the value of blood pressure is decisive due to its high prognostic significance. At the same time, blood pressure level is the most regulated variable in the stratification system. Experience shows that the effectiveness of a doctor’s actions in treating each individual patient and the achievement of success in controlling blood pressure among the country’s population as a whole largely depend on the coordination of actions and therapists. and cardiologists, which is ensured by a unified diagnostic and therapeutic approach. It was this task that was considered as the main one in the preparation recommendations .

Target blood pressure level

The intensity of treatment for a patient with hypertension is largely determined by the goal set in terms of reducing and achieving a certain level of blood pressure. When treating patients with hypertension, blood pressure should be less than 140/90 mmHg. which is its target level. If the prescribed therapy It is advisable to reduce blood pressure to lower values. In patients with a high and very high risk of cardiovascular complications, it is necessary to reduce blood pressure to 140/90 mmHg. or less within 4 weeks. In the future, subject to good tolerance, it is recommended to reduce blood pressure to 130-139/80-89 mm Hg. When carrying out antihypertensive therapy It should be kept in mind that it may be difficult to achieve a systolic blood pressure level of less than 140 mm Hg. in patients with diabetes mellitus, target organ damage, in elderly patients and those already having cardiovascular complications. Achieving a lower target blood pressure level is possible only if it is well tolerated and may take longer than reducing it to less than 140/90 mmHg. If lowering blood pressure is poorly tolerated, it is recommended to lower it in several stages. At each stage, blood pressure decreases by 10-15% from the initial level in 2-4 weeks. followed by a break to allow the patient to adapt to lower blood pressure values. The next stage of reducing blood pressure and, accordingly, strengthening antihypertensive therapy in the form of increasing doses or the number of drugs taken is possible only if the already achieved blood pressure values ​​are well tolerated. If moving to the next stage causes a deterioration in the patient's condition, it is advisable to return to the previous level for some more time. Thus, a decrease in blood pressure to the target level occurs in several stages, the number of which is individual and depends on both the initial blood pressure level and the tolerability of antihypertensive drugs. therapy. The use of a staged scheme for lowering blood pressure, taking into account individual tolerance, especially in patients with a high and very high risk of complications, allows one to achieve the target blood pressure level and avoid episodes of hypotension, which are associated with an increased risk of developing myocardial infarction and cerebral stroke. When reaching the target blood pressure level, it is necessary to take into account the lower limit of reducing systolic blood pressure to 110-115 mm Hg. and diastolic blood pressure up to 70-75 mm Hg. and also ensure that during treatment there is no increase in pulse blood pressure in elderly patients, which occurs mainly due to a decrease in diastolic blood pressure.

Experts divided all classes of antihypertensive drugs into primary and additional (Table 1). The recommendations note that all major classes of antihypertensive drugs (ACE inhibitors, angiotensin receptor blockers, diuretics, calcium channel blockers, b-blockers) reduce blood pressure equally; each drug has proven effects and its own contraindications in certain clinical situations; In most patients with hypertension, effective blood pressure control can only be achieved with combined therapy, and in 15-20% of patients, blood pressure control cannot be achieved with a two-component combination; Fixed combinations of antihypertensive drugs are preferable.

Deficiencies in the management of hypertension are usually associated with undertreatment due to inappropriate drug or dose selection, lack of synergism when using drug combinations, and problems associated with treatment adherence. It has been shown that combinations of drugs always have advantages over monotherapy in lowering blood pressure.

Prescribing combinations of antihypertensive drugs can solve all these problems, and therefore their use is recommended by authoritative experts in terms of optimizing the treatment of hypertension. Recently, it has been shown that certain combinations of drugs not only have benefits in controlling blood pressure, but also improve the prognosis in individuals with established hypertension, whether associated with other diseases or not. Since the doctor has a huge selection of different antihypertensive combinations (Table 2), the main problem is to choose the best combination with the greatest evidence for the optimal treatment of patients with hypertension.

The section “Drug therapy” emphasizes that in all patients with hypertension it is necessary to achieve a gradual reduction in blood pressure to target levels. Particular care should be taken to reduce blood pressure in the elderly and in patients who have had myocardial infarction and stroke. The number of drugs prescribed depends on the initial blood pressure level and concomitant diseases. For example, with grade 1 hypertension and the absence of a high risk of complications, it is possible to achieve target blood pressure with monotherapy in approximately 50% of patients. For grade 2 and 3 hypertension and the presence of high-risk factors, in most cases a combination of two or three drugs may be required. Currently, it is possible to use two strategies for initial therapy of hypertension: monotherapy and low-dose combined therapy followed by increasing the amount and/or dose of the drug if necessary (Scheme 1). Monotherapy at the start of treatment may be chosen for patients at low or intermediate risk. A low-dose combination of two drugs should be preferred in patients at high or very high risk of complications. Monotherapy is based on finding the optimal drug for the patient; transition to combined therapy is advisable only if there is no effect of the latter. Low-to-call combined Therapy at the start of treatment involves the selection of an effective combination of drugs with different mechanisms of action.

Each of these approaches has its own advantages and disadvantages. The advantage of low-dose monotherapy is that if the drug is successfully selected, the patient will not have to take another drug. However, the monotherapy strategy requires the doctor to painstakingly search for the optimal antihypertensive drug for the patient with frequent changes in medications and their dosages, which deprives the doctor and the patient of confidence in success and ultimately leads to a decrease in patient adherence to treatment. This is especially true for patients with stage 1 and 2 hypertension, most of whom do not experience discomfort from increased blood pressure and are not motivated to treatment.

At combined Therapy in most cases, the prescription of drugs with different mechanisms of action allows, on the one hand, to achieve target blood pressure, and on the other, to minimize the number of side effects. Combination therapy also makes it possible to suppress counterregulatory mechanisms of increased blood pressure. The use of fixed combinations of antihypertensive drugs in one tablet increases patient adherence to treatment. Patient with blood pressure ≥ 160/100 mm Hg. those at high and very high risk, full-dose combination therapy can be prescribed at the start of treatment. In 15-20% of patients, blood pressure control cannot be achieved when using two drugs. In this case, a combination of three or more drugs is used.

As noted earlier, along with monotherapy, combinations of two, three or more antihypertensive drugs are used to control blood pressure. Combination therapy has many advantages: enhancing the antihypertensive effect due to the multidirectional effects of drugs on the pathogenetic mechanisms of hypertension development, which increases the number of patients with a stable decrease in blood pressure; reducing the incidence of side effects, both due to lower doses of combined antihypertensive drugs, and due to the mutual neutralization of these effects; ensuring the most effective organ protection and reducing the risk and number of cardiovascular complications. However, it must be remembered that combination therapy is taking at least two medications, the frequency of administration of which may be different. Therefore, the use of drugs in the form of combination therapy must meet the following conditions: the drugs must have a complementary effect; an improvement in the result should be achieved when they are used together; drugs must have similar pharmacodynamic and pharmacokinetic parameters, which is especially important for fixed combinations.

Priority of rational combinations of antihypertensive drugs

RMOAG experts suggest dividing combinations of two antihypertensive drugs into rational (effective), possible and irrational. American experts who 2010 presented new algorithm of combined antihypertensive therapy (Table 3), occupy in this question almost the same positions. This position fully coincides with the opinion of European experts on hypertension, expressed in November 2009 by questions combination therapy and presented in Figure 1.

The Russian recommendations emphasize that the full benefits of combination therapy are inherent only in rational combinations of antihypertensive drugs (Table 2). Among the many rational combinations, some deserve special attention, having advantages not only from the theoretical standpoint of the main mechanism of action, but also practically proven high antihypertensive effectiveness. First of all, this is a combination of an ACE inhibitor with a diuretic, which enhances the advantages and eliminates the disadvantages. This combination is the most popular in the treatment of hypertension due to its high antihypertensive effectiveness, protection of target organs, good safety and tolerability. The published recommendations of the American Society of Hypertension (ASH) for combination therapy of hypertension (Table 3) also give priority (more preferable) to combinations of drugs that block the activity of the renin-angiotensin system (angiotensin receptor blockers or ACE inhibitors) with diuretics or calcium antagonists.

The drugs potentiate each other’s action due to their complementary effect on the main links in blood pressure regulation and blockade of counter-regulatory mechanisms. A decrease in circulating fluid volume due to the saluretic effect of diuretics leads to stimulation of the renin-angiotensin system (RAS), which is counteracted by an ACE inhibitor. In patients with low plasma renin activity, ACE inhibitors are usually not effective enough, and the addition of a diuretic, which leads to increased RAS activity, allows the ACE inhibitor to realize its effect. This expands the range of patients who respond to therapy, and target blood pressure levels are achieved in more than 80% of patients. ACE inhibitors prevent hypokalemia and reduce the negative effect of diuretics on carbohydrate, lipid and purine metabolism.

ACE inhibitors are widely used in the treatment of patients with hypertension, acute forms of coronary artery disease, and chronic heart failure. One of the representatives of a large group of ACE inhibitors is lisinopril. The drug has been studied in detail in several large-scale clinical studies. Lisinopril has demonstrated preventive and therapeutic efficacy in heart failure, including after acute MI, and in concomitant diabetes mellitus (GISSI 3, ATLAS, CALM, IMPRESS studies). In the largest clinical study on the treatment of hypertension with various classes of drugs, ALLHAT, among those taking lisinopril, the incidence of type 2 diabetes significantly decreased.

The Russian pharmacoepidemiological study PYTHAGOR III studied the preferences of practicing physicians in the choice of antihypertensive therapy. The results were compared with the previous phase of the PYTHAGORUS I study in 2002. According to this survey of doctors, the structure of antihypertensive drugs that are prescribed to patients with hypertension in real practice is represented by five main classes: ACE inhibitors (25%), β-blockers (23%), diuretics (22%), calcium antagonists (18%). ) and angiotensin receptor blockers. In comparison with the results of the PYTHAGOR I study, there is a decrease in the proportion of ACE inhibitors by 22% and β-blockers by 16%, an increase in the proportion of calcium antagonists by 20% and an almost 5-fold increase in the proportion of angiotensin II receptor blockers.

In the structure of drugs of the class of ACE inhibitors, the largest shares are enalapril (21%), lisinopril (19%), perindopril (17%), fosinopril (15%) and ramipril (10%). However, in recent years there has been a tendency to increase the importance and frequency of use of combination antihypertensive therapy to achieve the target level in patients with hypertension. According to the PYTHAGORUS III study, in comparison with 2002, the vast majority (about 70%) of doctors prefer to use combination therapy in the form of free (69%), fixed (43%) and low-dose combinations (29%) and only 28% continue to use the tactic monotherapy. Among combinations of antihypertensive drugs, 90% of doctors prefer to prescribe ACE inhibitors with a diuretic, 52% prefer β-blockers with a diuretic, 50% of doctors prescribe combinations that do not contain diuretics (calcium antagonists with ACE inhibitors or β-blockers).

One of the most optimal combinations of an ACE inhibitor and a diuretic is the drug "Co-Diroton"® (Gedeon Richter) - a combination of lisinopril (10 and 20 mg) and hydrochlorothiazide (12.5 mg), the components of which have a good evidence base. "Co-Diroton" can be used if a patient with hypertension has chronic heart failure, severe left ventricular hypertrophy, metabolic syndrome, excess body weight, or diabetes mellitus. The use of Co-Diroton is justified for refractory hypertension, as well as for a tendency to increase the number of heart contractions.

Taking into account the growing interest of doctors in the use of combination therapy, RMOAG experts for the first time presented a table indicating the preferential indications for prescribing rational combinations (Table 4).

New leader

combination therapy

The combination of a calcium antagonist and an ACE inhibitor has become increasingly popular in recent years, with an increasing number of clinical trials and the emergence of new combined dosage forms. The calcium antagonist amlodipine has been studied in many clinical projects. The drug effectively controls blood pressure and is one of the most studied calcium antagonists in various clinical situations. Along with the assessment of blood pressure-lowering effects, the vasoprotective and antiatherosclerotic properties of this calcium antagonist have been actively studied. Two studies, PREVENT and CAMELOT, were conducted using methods that visualize the vascular wall in patients with coronary artery disease, which assessed the effect of amlodipine on the development of atherosclerosis. Based on the results of these and other controlled studies, experts from the European Society of Hypertension/European Society of Cardiology included in the recommendations the presence of atherosclerosis of the carotid and coronary arteries in patients with hypertension as one of the indications for the primary use of calcium antagonists. The proven anti-ischemic and anti-atherosclerotic properties of amlodipine allow it to be recommended for blood pressure control in patients with hypertension in combination with coronary artery disease.

From the point of view of reducing the risk of developing cardiovascular complications and improving the prognosis for hypertension (the main goal in the treatment of this disease), this drug has demonstrated great protective potential in such comparative studies as ALLHAT, VALUE, ASCOT, ACCOMPLISH.

Clinical practice and the results of several clinical studies provide strong arguments in favor of this combination. The most important data in this regard were data from studies such as ASCOT, in which the majority of patients received a free combination of a calcium antagonist and an ACE inhibitor; recent post hoc analysis of the EUROPA study; new analysis of the ACTION study and especially the ACCOMPLISH study. This project compared the effect of two initial combination therapy regimens on the incidence of cardiovascular events in 10,700 patients with high-risk hypertension (60% of patients had diabetes mellitus, 46% had coronary artery disease, 13% had a history of stroke, mean age 68 years, average body mass index 31 kg/m2) - ACE inhibitor benazepril with amlodipine or with the thiazide diuretic hydrochlorothiazide.

Initially, it was shown that when patients were transferred to a fixed combination of drugs, blood pressure control significantly improved, and after three years this study was stopped early because there was clear evidence of higher effectiveness of the combination of a calcium antagonist with an ACE inhibitor. With equal blood pressure control in this group, there was a significant reduction in the risk of developing cardiovascular complications (primary endpoint) compared to the group receiving a combination of an ACE inhibitor and a diuretic - by 20%. The results of this study suggest that the combination of calcium antagonists with ACE inhibitors has good prospects for wider use in clinical practice. It can be assumed that such a combination may be especially in demand in the treatment of patients with hypertension in combination with coronary artery disease.

An increase in blood pressure-lowering effect when using a combination of calcium antagonists and ACE inhibitors is accompanied by a decrease in the incidence of adverse reactions, in particular swelling of the legs, characteristic of dihydropyridine calcium antagonists. There is evidence that cough associated with ACE inhibitors is also attenuated by calcium antagonists, including amlodipine.

Fixed combinations:

more benefits

For combination therapy of hypertension, both free and fixed combinations of drugs can be used. RMOAG experts recommend that practitioners in most cases give preference to fixed combinations of antihypertensive drugs containing two drugs in one tablet. It is possible to refuse to prescribe a fixed combination of blood pressure-lowering drugs only if it is absolutely impossible to use it if there are contraindications to one of the components. The document notes that a fixed combination: will always be rational; is the most effective strategy for achieving and maintaining target blood pressure levels; provides better organoprotective effect and reduces the risk of complications; allows you to reduce the number of pills taken, which significantly increases patient adherence to treatment.

The previously mentioned ACCOMPLISH study was the first to conduct a comparative study of the effectiveness of fixed combinations. One of the first fixed combinations in our country is the drug “Equator” (containing the calcium antagonist amlodipine and the ACE inhibitor lisinopril). Both of these drugs have a good evidence base, including large-scale clinical studies. Clinical studies have demonstrated the high antihypertensive effectiveness of the drug "Equator". Among fixed combination drugs in the PYTHAGOR III study, doctors named 32 trade names, among which combination drugs of ACE inhibitors and diuretics were most often noted, as well as “Equator” in 17%.

Experts believe that prescribing a fixed combination of two antihypertensive drugs can be the first step in treating patients at high cardiovascular risk or immediately follow monotherapy.

The role of other combinations

in the treatment of hypertension

Possible combinations of antihypertensive drugs include the combination of a dihydropyridine and non-dihydropyridine CB, ACE inhibitors + β-blockers, ARBs + β-blockers, ACE inhibitors + ARBs, a direct renin inhibitor or an α-blocker with all major classes of antihypertensive drugs. The use of these combinations in the form of two-component antihypertensive therapy is currently not absolutely recommended, but is not prohibited. However, making a choice in favor of such a combination of drugs is permissible only if you are completely sure that it is impossible to use rational combinations. In practice, patients with hypertension who have coronary artery disease and/or chronic heart failure are simultaneously prescribed ACE inhibitors and β-blockers. However, as a rule, in such situations, the prescription of β-blockers occurs mainly due to the presence of coronary artery disease or heart failure, i.e. according to independent indications (Table 5).

Irrational combinations, the use of which does not potentiate the antihypertensive effect of drugs and/or increase side effects when used together, include: combinations of different drugs belonging to the same class of antihypertensive drugs, β-blockers + non-dihydropyridine calcium antagonist, ACE inhibitor + potassium-sparing diuretic, β-blocker + centrally acting drug.

Question Combinations of three or more drugs have not yet been sufficiently studied, since there are no results from randomized controlled clinical trials examining triple combinations of antihypertensive drugs. Thus, the antihypertensive drugs in these combinations are grouped together on a theoretical basis. However, in many patients, including patients with refractory hypertension, only with the help of three or more component antihypertensive therapy can the target blood pressure level be achieved.

Conclusion

In new recommendations for the treatment of hypertension RMOAG/VNOK pay special attention questions combination therapy as a critical component of success in preventing cardiovascular complications. The increased interest in combination therapy for hypertension, numerous clinical studies, and most importantly, their encouraging results increasingly clearly indicate an important trend in cardiology: an emphasis on the development of multicomponent dosage forms. Among fixed dosage forms, experts distinguish combinations of drugs that block the activity of the RAAS (ACE inhibitors, etc.) with calcium antagonists or diuretics.

Literature

1. Russian Medical Society for arterial arterial hypertension. Russian recommendations (third revision). Cardiovascular Therapy and Prevention 2008; No. 6, Appendix 2.

2. The Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology. 2007 Guidelines for the management of arterial hypertension. J Hypertens 2007, 25: 1105-1187.

3. Russian Medical Society for arterial hypertension (RMOAH), All-Russian Scientific Society of Cardiologists (VNOK). Diagnosis and treatment arterial hypertension. Russian recommendations (fourth revision), 2010.

4. Mancia G. Laurent S. Agabiti-Rosei E. et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertension 2009; 27: 2121-2158.

5. Gradman A.H. Basile J.N. Carter B.L. et al. Combination therapy in hypertension. J Am Soc Hypertens 2010; 4: 42-50.

6. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic: the Antihypertensive and Lipid Lowering treatment to prevent Heart Attack Trial (ALLHAT). JAMA, 2002; 288:2981-97.

7. Leonova M.V. Belousov D.Yu. Steinberg L.L. analytical group of the PYTHAGORUS study. Analysis of medical practice of antihypertensive therapy in Russia (according to the PYTHAGOR III study). Farmateka 2009, no. 12: 98-103.

8. Leonova M.V. Belousov D.Yu. analytical group of the PYTHAGORUS study. The first Russian pharmacoepidemiological study of arterial hypertension. Qualitative Clinical Practice, 2002. No. 3: 47-53.

9. Pitt B. Byington R.P. Furberg C.D. et al. Effect of amlodipine on the progression of atherosclerosis and the occurrence of clinical events. PREVENT Investigators. Circulation 2000, 102: 1503-1510.

10. Nissen S.E. Tuzcu E.M. Libby P. et al. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. JAMA, 2004; 292:2217-2225.

11. Julius S. Kjeldsen S.E. Weber M. et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomized trial. Lancet, 2004; 363: 2021-2031.

12. Dahlof B. Sever P.S. Poulter N.R. et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomized controlled trial. Lancet 2005, 366: 895-906.

13. Jamerson K.A. Weber M.A. Bakris G.L. et al. on behalf of the ACCOMPLISH investigators. Benazepril plus amlodipine or hydrochlorotiazide for hypertension in high-risk patients. N Engl J Med 2008; 359: 2417-2428.

14. Bertrand M.E. Ferrari R. Remme W.J. et al. Clinical synergy of perindopril and calcium-channel blocker in the prevention of cardiac events and mortality in patients with coronary artery disease. Post hoc analysis of the EUROPA study. Am Heart J, 2010; 159: 795-802.

15. Elliott H.L. Meredith P.A. Preferential benefits of nifedipine GITS in systolic hypertension and in combination with RAS blockade: further analysis of the `ACTION` database in patients with angina. J Human Hypertension, 25 Feb. 2010; doi:10.1038/jhh.2010.19.

Novel Russian Recommendations on Arterial Hypertension – Priority for Combination Therapy (Russian Medical Society on Arterial Hypertension, Section of Evidence Based Hypertensiology)

Since the release of the third version of the Russian recommendations on arterial hypertension (AH) in 2008, new data have been obtained that necessitate a revision of this basic document. At the initiative of the Russian Medical Society for Hypertension (RMAS) and the All-Russian Scientific Society of Cardiology (VNOK), recommendations were developed based on the provisions proposed by experts from the European Society of Arterial Hypertension (ESAH) and the European Society of Cardiology (ESC) in 2009.a also the results of major Russian studies on the problem of hypertension.

As before, the main goal of treating patients with hypertension is to minimize the risk of developing cardiovascular complications (CVC) and death from them. To achieve this goal, it is necessary not only to reduce blood pressure to the target level, but also to correct all modifiable risk factors, prevent and slow the rate of progression and/or reduce target organ damage, as well as treat associated and concomitant diseases - coronary heart disease, diabetes mellitus ( SD), etc. When treating patients with hypertension, blood pressure should be less than 140/90 mmHg. which is his target level.

In addition to monotherapy, combinations of 2, 3 or more antihypertensive drugs are used in the treatment of hypertension. In recent years, in accordance with international and domestic recommendations for the treatment of hypertension, there has been a tendency to increase the importance and frequency of use of combination antihypertensive therapy to achieve the target blood pressure level. Combination therapy has many advantages: enhancing the antihypertensive effect due to the multidirectional action of drugs on the pathogenetic links of hypertension, which increases the number of patients with a stable decrease in blood pressure. In combination therapy, in most cases, the prescription of drugs with different mechanisms of action allows, on the one hand, to achieve the target blood pressure level, and on the other, to minimize the number of side effects. Combination therapy also makes it possible to suppress counterregulatory mechanisms of increased blood pressure. The use of fixed combinations of antihypertensive drugs in one tablet increases patient adherence to treatment.

Combinations of 2 antihypertensive drugs are divided into rational (effective), possible and irrational. All the advantages of combination therapy are inherent only in rational combinations of antihypertensive drugs. These include angiotensin-converting enzyme inhibitor (ACE) + diuretic; angiotensin II receptor blocker (ARB) + diuretic; ACE inhibitor + calcium antagonist; BRA + AK; dihydropyridine calcium antagonist + β-blocker; calcium antagonist + diuretic; β-blocker + diuretic.

One of the most effective is considered to be a combination of ACE inhibitors and diuretics. Indications for use of this combination are diabetic and non-diabetic nephropathy; microalbuminuria (MAU); left ventricular hypertrophy; SD; metabolic syndrome (MS); old age; isolated systolic hypertension. The combination of antihypertensive drugs of these classes is one of the most frequently prescribed, one of them - a fixed combination of perindopril with indapamide (noliprel A and noliprel A forte) according to the PYTHAGORUS study - is the most popular among doctors.

News of combination therapy for hypertension (fixed combinations)

Previously, it was reported about the emergence of a new perindopril arginine salt, called “Prestarium A”, instead of tertbutylamine salt. Then a new noliprel A was proposed, in which the arginine salt of perindopril at a dose of 2.5 and 5 mg is presented in combination with indapamide 0.625 (noliprel A) and 1.25 mg (noliprel A forte), respectively.

The effectiveness of noliprel has been studied in many international and Russian clinical studies. One of them is the Russian program STRATEGY (COMPARATIVE PROGRAM to evaluate the effectiveness of noliprel in patients with arterial HYPERTENSION with insufficient blood pressure control). This study examined the effectiveness of a fixed combination of perindopril/indapamide (noliprel and noliprel forte) in 1726 hypertensive patients with inadequate blood pressure control.

The OPTIMAX II study examined the effect of MS according to NCEP ATPIII criteria on blood pressure control in patients with hypertension receiving noliprel. This prospective observation lasting 6 months included 24,069 patients (56% men, mean age 62 years, 18% had diabetes, mean blood pressure at inclusion 162/93 mmHg MS in 30.4%). The frequency of normalization of blood pressure ranged from 64 to 70% depending on the regimen of noliprel forte - as initial therapy, replacement or additional therapy, and did not depend on the presence of MS.

Adequate control over blood pressure levels using the combination drug Noliprel A forte provides organ protection. The PICXEL study showed that the use of a fixed combination of noliprel forte was more effective in reducing left ventricular hypertrophy than monotherapy with high doses of the ACE inhibitor enalapril, and provided better blood pressure control. This was the first study to examine the effect of a combination drug as initial therapy on hypertrophied myocardium.

According to the PREMIER study (Preterax in Albuminuria Regression), noliprel forte, to a greater extent than enalapril at a high dose of 40 mg, reduced the severity of albuminuria in patients with type 2 diabetes and hypertension, regardless of the effect on blood pressure. This controlled study included 481 patients with type 2 diabetes, hypertension and MAU. Patients were randomized to receive either perindopril 2 mg/indapamide 0.625 mg (increased to 8 mg and 2.5 mg, respectively) or enalapril 10 mg (increased to 40 mg as needed) for 12 months.

The use of a fixed combination of noliprel forte in patients with type 2 diabetes in the ADVANCE study (Action in Diabetes and VAscular disease - preterax and Diamicron MR Controlled Evaluation) significantly reduced the risk of developing major cardiovascular events, including death. The study included 11,140 patients with type 2 diabetes and a high risk of complications. During long-term follow-up (average 4.3 years), the relative risk of developing major macro- and microvascular complications (primary endpoint) significantly decreased by 9% (p = 0.04). Treatment with noliprel in patients with type 2 diabetes led to a significant reduction in the risk of death from all causes by 14% (p=0.03) and from cardiovascular causes by 18% (p=0.03). In the active treatment group, the risk of developing coronary complications was significantly lower by 14% (p = 0.02) and renal complications by 21% (p 140 mm Hg and/or diastolic blood pressure (DBP) >95 mm Hg. Antihypertensive therapy upon inclusion in the program was represented by β-blockers, AC, ACE inhibitors (except Prestarium A), diuretics (except Arifon, Arifon Retard), centrally acting drugs, ARBs in the form of monotherapy or free combinations of all included in previous antihypertensive therapy. During the study, patients were prescribed a combination of perindopril arginine/indapamide (noliprel A forte 1 tablet per day). For patients who had previously received ACE inhibitors or diuretics for antihypertensive purposes, these drugs were replaced with noliprel A forte from the next day of therapy. Subsequently, after 4 weeks of therapy at the level. SBP ≥130 mmHg and/or DBP ≥80 mmHg. The dose of Noliprel A forte was doubled (2 tablets per day).

A twelve-week period of active observation was completed by 2296 hypertensive patients with high and very high risk of developing cardiovascular complications (31% of men and 69% of women) at the age of 57.1 years. Initial clinical blood pressure was 159.6/95.5 mm Hg. After 4 weeks, there was a significant and clinically significant decrease in SBP to 135 mmHg. (p

Currently, arterial hypertension is a leading risk factor for the development of diseases such as myocardial infarction and stroke, which mainly determine high mortality rates in the Russian Federation. Despite the fact that about 85% of patients are aware of their disease, only 68% take medications, only 25% are effectively treated, and only 20% of patients control target blood pressure levels. This is what accounts for the widespread prevalence of the disease. In 2018, the World Health Organization plans to review blood pressure control indicators and their correspondence to the severity of hypertension: if now the first degree of hypertension starts from 140-159 and 90-99 mmHg, then WHO recommends reducing these values ​​to 130 -139 and 85-89 mmHg.

Definition

Hypertension is a chronic disease of the cardiovascular system, the main symptom of which is systematic arterial hypertension, not associated with the presence of pathological processes in other organs. Normal threshold blood pressure values ​​are 120 – 129 and/or 80 – 84 mmHg; the concept of office hypertension is also currently distinguished - measuring blood pressure at home with an indicator of 130 and 85 mmHg.

In the mechanism of increased blood pressure, two groups of causes and factors are distinguished: neurogenic and humoral. Neurogenic ones have an effect through the sympathetic nervous system, affecting the tone of arterioles, and humoral ones are associated with an increased release of biologically active substances that have a pressor effect.

Classification

The blood pressure classification presented is currently used for persons over 18 years of age:

• Optimal blood pressure is less than 120 and 80 mmHg.
• Normal blood pressure is 120 - 129 and/or 80 - 84 mmHg.
• High normal blood pressure 130 - 139 and/or 85 - 89 mmHg.
• 1st degree of hypertension, blood pressure 140 - 159 and/or 90 - 99 mmHg.
• Stage 2 hypertension: blood pressure 160 - 179 and/or 100 - 109 mmHg.
• Stage 3 hypertension: blood pressure more than 180 and/or 110 mmHg.
• Isolated systolic hypertension; blood pressure more than 140 and less than 90 mmHg.

In situations where systolic and diastolic pressure do not belong to the same category, the degree is set to a higher value. Symptomatic arterial hypertension (secondary) is also distinguished.

Advice! A diagnosis can be made only after measuring pressure twice on each arm with an interval of 5 minutes, with the exclusion of factors that increase blood pressure at least 30 minutes before the test.

It should be noted that the parameters of high blood pressure are quite conditional, since there is a direct connection between the level of pressure and the risk of cardiovascular diseases, starting with indicators of 115 and 75 mmHg. To assess the pressure level on each arm, at least two measurements are required with a break of 1 minute. If there is a difference in values ​​of more than 5 mmHg. additional measurement is required. The minimum of three results is taken as the final result. To correctly determine the results, it is necessary to meet certain definition conditions, namely:

1. Avoid coffee, tea, and alcohol an hour before the test;
2. Stop smoking in 30 minutes;
3. Cancellation of drugs - sympathomimetics, including eye and nasal drops;
4. Lack of physical and emotional stress.

Blood pressure is measured after a five-minute rest. The patient sits on a chair in a comfortable position, legs are not crossed, the hand is at heart level and lies on the table in a relaxed state.

Diagnostics

Examination and differential diagnosis for arterial hypertension includes the following studies:

• Collection of information about the history of the present disease and the patient’s complaints. Information is learned about symptoms of target organ damage and hereditary predisposition;
• Repeated blood pressure measurement - the diagnosis is made when blood pressure is high after twice measuring it on two different visits.
• Physical examination includes anthropometry - measurement of waist circumference, height, body weight, calculation of body mass index. Auscultation of the heart and main arteries is also performed, and the pulse in the radial arteries is counted in order to detect arrhythmia.
• Laboratory research. At the first stage, the following tests are carried out: general blood and urine analysis, fasting glucose, total cholesterol, high and low density lipoproteins, triglycerides, Potassium, Sodium. According to indications, at the second stage, creatinine clearance, glomerular filtration rate, uric acid level, protein in urine (microalbuminuria), urine according to Nechiporenko, ALT, AST, and oral glucose tolerance test are measured.
• Instrumental diagnostics include electrocardiography with stress tests, echocardiography to clarify the morphological parameters of myocardial damage, duplex scanning of the brachiocephalic arteries, determination of pulse wave velocity, ankle-brachial index, ultrasound examination of the kidneys, fundus examination, chest radiography, 24-hour blood pressure monitoring , assessment of general cardiovascular risk using specialized scales.

Treatment

The main goal of conservative therapy is to minimize the risk of complications and target organ damage. For this purpose, blood pressure is reduced to a normal value, exogenous risk factors are corrected, the course and progression of target organ damage is prevented or slowed down, and existing concomitant diseases are corrected.

These measures are recommended for all patients, thereby providing primary prevention in patients with high normal blood pressure and reducing the need for drug therapy in patients with arterial hypertension. Clinical recommendations for lifestyle changes include the following main aspects:

• Daily limit of table salt intake to 3-5 grams per day.
• Refusal to drink alcohol-containing drinks (maximum dose of alcohol per week is 140g for men and 80g for women).
• Normalization of diet and eating behavior: split meals 5-6 times a day in small portions with a rational ratio of proteins, fats and carbohydrates.
• Reducing body mass index to physiological numbers.
• Increase physical activity.
• Quitting smoking tobacco products.

Drug treatment

The selection of an antihypertensive drug is carried out on an individual basis. In modern treatment of hypertension, 5 groups of drugs are used:

1. Adenosine converting enzyme (ACE) inhibitors. Slow down the development and progression of target organs, for example, hypertrophy of the left ventricle of the myocardium, proteinuria, reduces microalbuminuria and slows down the decline in the filtration function of the kidneys;
2. Angiotensin 2 receptor blockers. Most effective in patients with increased activity of the renin-angiotensin-aldosterone system. The number of side effects is reduced compared to ACE inhibitors, but the effect is milder and less pronounced;
3. Calcium channel blockers. Slow down the intracellular calcium current in peripheral vessels, thereby reducing the sensitivity of blood vessels to amines. There are two groups of BCAs: dihydroperidines and non-dihydroperidines. The former have a pronounced selective effect on vascular smooth muscle and do not cause a decrease in the contractile function of the myocardium. Non-dihydroperidines have inotropic and dromotropic effects on the heart muscle;
4. Beta blockers - reduce the frequency and strength of heart contractions, as well as the secretion of renin, thereby reducing the load on the heart;
5. Diuretics. They reduce the volume of circulating blood and minute volumetric blood flow, which reduces the preload on the heart and reduces the severity of arterial hypertension.

Each of these groups of drugs has its own indications and contraindications and can be used as monotherapy or as part of complex drug treatment.

Important! Do not try to combine medications yourself, as this may cause a number of side effects. To correctly identify the cause of the disease and prescribe medications, consult a doctor.

The most rational combinations are ACE inhibitors + diuretic; Beta blockers + diuretic; Calcium antagonist + beta blocker.

Irrational combinations that lead to increased side effects of drugs include a combination of drugs of the same class, as well as the following combinations: ACE inhibitors + potassium-sparing diuretic; beta blocker + non-dihydroperidine calcium antagonist.

In some cases, drugs of other groups may be prescribed in the presence of somatic pathology, for example, antiplatelet agents, anticoagulants and statins.

In some cases, surgical treatment may be recommended if the main components of therapy are ineffective or in advanced cases with target organ damage. Radiofrequency denervation of the renal arteries is recommended, which leads to a stable decrease in office blood pressure.

Conclusion

Thus, arterial hypertension is one of the most common pathological conditions among the population. There is a need to periodically monitor blood pressure numbers, as well as regularly visit a therapist and, if there is a risk of hypertension or already formed hypertension, follow the recommendations of the attending physician on taking medications and monitoring blood pressure, and also be monitored by a cardiologist.

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Seminar "Arterial hypertension in 2016: modern approaches to classification, diagnosis and treatment"

Conducts: Republican Medical University

Date:

Arterial hypertension (AH) is the most important modifiable cardiovascular risk factor. There is a generally accepted connection between high blood pressure (BP) and an increased risk of fatal and non-fatal myocardial infarction and stroke, as well as accelerated progression of chronic kidney disease.

This report briefly discusses modern ideas about the classification, diagnosis and treatment of hypertension. For this purpose, materials from a number of publications published in 2013-2014 were used. documents, including: 1) Recommendations of the European Society of Hypertension and the European Society of Cardiology (ESH / ESC) for the treatment of hypertension, 2013; 2) Clinical Guidelines for the treatment of hypertension of the American Society of Hypertension and the International Society of Hypertension (ASH / ISH), 2013); 3) Eighth US Joint National Committee Guidelines for the Management of High Blood Pressure in Adults (JNC-8).

Definition. The term hypertension refers to a condition in which there is sustained increase in blood pressure levels: systolic blood pressure ≥ 140 mm Hg. and/or diastolic blood pressure ≥ 90 mm Hg. The classification of blood pressure levels and degrees of hypertension is presented in Table 1.

Table 1. Classification of blood pressure levels (mm Hg) and degrees of hypertension

Highlight primary hypertension (the term “essential hypertension” is also used; we generally use the designation "hypertension" ), in which the increase in blood pressure is not directly related to any organ damage, and secondary (or “symptomatic”) hypertension , in which hypertension is associated with lesions of various organs/tissues (Table 2).

Among all persons with hypertension, the proportion of patients with hypertension is about 90%; The share of all symptomatic hypertension listed in Table 2 accounts for a total of about 10%. Among symptomatic hypertension, the most common are renal (up to half of the cases of symptomatic hypertension).

Table 2. Classification of hypertension by etiology

Primary hypertension (essential hypertension, hypertension)
Secondary hypertension (symptomatic):
Renal: 1. Renoparenchymatous 2. Renovascular 3. Hypertension in renin-producing tumors 4. Renoprival hypertension (after nephrectomy)	Endocrine: · Adrenal (for disorders in the cortical layer - Cushing's syndrome, for disorders in the medulla - pheochromocytoma) · Thyroid (with hyper- or hypothyroidism) · Hypertension in acromegaly, hyperparathyroidism, carcinoid · Hypertension while taking exogenous hormonal drugs (estrogens, gluco- and mineralocorticoids, sympathomimetics)
Hypertension in coarctation of the aorta	Pregnancy-related hypertension
Hypertension associated with neurological causes (for inflammatory and tumor lesions of the central nervous system)	Hypertension due to increased cardiac output (for example, isolated systolic hypertension with increased aortic wall stiffness in the elderly, hypertension with aortic valve insufficiency, hypertension with an arteriovenous fistula)

Classification of hypertension according to the degree of cardiovascular risk

The standard now is highlighting (and indicating when formulating a diagnosis) the degrees of additional cardiovascular risk in hypertension (Table 3); For this purpose, it is customary to take into account the presence in the patient, along with hypertension, of cardiovascular risk factors, target organ damage and concomitant diseases (Table 4).

Table 3. Levels of additional cardiovascular risk in hypertension

AG + (FR, POM, SZ)	Normal -120-129 / 80-84 mmHg.	High normal – 130-139 / 85-89	AH 1st degree – 140-159 / 90-99	AH 2nd degree – 160-179 / 100-109	Stage 3 hypertension – ≥180 / ≥110
	Average risk in the population	Average risk in the population	Low additional risk		additional risk
	Low additional risk	Low additional risk	Moderate additional risk	Moderate additional risk
≥3 FR or SD, POM	Moderate additional risk	High additional risk	High additional risk	High additional risk	Very high additional risk
	Very high additional risk	Very high additional risk	Very high additional risk	Very high additional risk	Very high additional risk

Notes: RF – risk factors, POM – target organ damage, SD – concomitant diseases, DM – diabetes mellitus (see Table 4). According to the Framingham criteria, the terms "low", "moderate", "high" and "very high" risk mean the 10-year probability of developing cardiovascular events (fatal and non-fatal)<15%, 15-20%, 20-30% и >30%, respectively.

Table 4. Cardiovascular risk factors, target organ damage and comorbidities in hypertension

Cardiovascular risk factors: Age (M ≥ 55, F ≥ 65 years) · Smoking Dyslipidemia (total cholesterol > 4.9 mmol/l or LDL cholesterol > 3.0 mmol/l or HDL cholesterol<1,0 (М) и <1,2 ммоль/л (Ж) или ТГ >1.7 mmol/l) · Fasting plasma glucose ≥ than in 2 measurements 5.6-6.9 mmol/l Impaired glucose tolerance · Obesity (body mass index ≥ 30 kg/m2) Abdominal obesity (waist circumference ≥102 cm (M) and ≥88 cm (W) · Cardiovascular diseases in relatives under 55 years old (M) / 65 (F)

Target organ damage: High pulse blood pressure in elderly people (≥ 60 mm Hg) · LV hypertrophy – according to ECG* (Sokolov-Lyon index > 3.5 mV or Cornell product > 2440 mm x ms) or according to echocardiogram** (LV myocardial mass index ≥ 115 g/m2 (M) / ≥ 95 g/m 2 (F)) Thickening of the carotid artery wall (intima-media thickness > 0.9 mm) or plaque · Velocity of pulse wave propagation*** (on the carotid – femoral arteries) >10 m/s · Ankle-brachial index****< 0,9 · Glomerular filtration rate (GFR) 30-60 ml/min/1.73m2 Microalbuminuria 30-300 mg/day or mg/ml

Related diseases: · Previous strokes, transient ischemic attacks · Coronary heart disease Chronic heart failure with reduced systolic function of the left ventricle, as well as with preserved ejection fraction Chronic kidney disease (GFR<30 мл/мин/1,73м 2 ; протеинурия >300 mg/day) Peripheral arterial disease with symptoms Severe retinopathy (hemorrhages, exudates, edema)

Diabetes mellitus: · Diagnostics: glycosylated hemoglobin ≥ 7.0% or fasting plasma glucose (≥ 8 hours without eating) 2 times ≥7.0 mmol/L or glucose 2 hours after a glucose load (75 g glucose) ≥11.1 mmol/L

Notes: CS – cholesterol; LDL – low density lipoproteins; HDL – high density lipoproteins; TG – triglycerides; ECG – electrocardiogram; LV – left ventricle; GFR – glomerular filtration rate.

* – ECG – diagnosis of LV hypertrophy . Sokolov-Lyon index: SV1 + (RV5 or RV6); Cornell product for men: (RavL + SV3) x QRS (ms), for women: (RavL + SV3 +8) x QRS (ms).

** –Echocardiographic diagnosis of LV hypertrophy. For this purpose, the American Society of Echocardiography - ASE formula is currently widely used, in which the mass of the LV myocardium (LVMM) = 0.8 x (1.04 x (LV EDR + LVAD + TMZH) 3 – (LV EDR) 3)) + 0.6 , where LV EDR is the end-diastolic size of the LV; LVTS – thickness of the posterior wall of the left ventricle in diastole; VSD – thickness of the interventricular septum in diastole. To calculate the LVMM index, the value of LVMM obtained using this formula divided by the surface area of ​​the patient's body (the table shows the normal values ​​of the LVMM index with this calculation option). Some experts consider it more acceptable to index LVMM not by body surface area, but by the patient’s height by a factor of 2.7 (height 2.7) or height by a power of 1.7 (height 1.7) - to improve the identification of LV hypertrophy in overweight individuals body or obese.

*** – Pulse wave propagation speed assessed using mechanical or Doppler pulse wave recording in the carotid and femoral arteries.

**** –Ankle-brachial index - the ratio of systolic blood pressure at the ankle (cuff - on the distal leg) to systolic blood pressure at the shoulder.

Figure 1 shows a version of the SCORE scale recommended by European experts to assess the level of cardiovascular risk for countries with an initially high population level of such risk (including Kazakhstan). To use the scale correctly, you should find the box that corresponds to the indicators of gender, age, systolic blood pressure and total cholesterol that a particular patient has. The number indicated in the box represents the approximate 10-year risk of death from cardiovascular causes (expressed as a percentage). According to the SCORE scale, the 10-year risk of death from cardiovascular causes is classified into the following categories: very high (≥ 10%), high (5-9%), moderate (1-4%) and low (0%).

Figure 1. Risk score (SCORE - Systematic COronary Risk Evaluation) assessing the 10-year risk of death from cardiovascular diseases depending on gender, age, smoking, blood pressure levels and total serum cholesterol (option recommended by ESC experts for countries having a high level of cardiovascular risk in the population, including for Kazakhstan) - suitable for people in the general population who do not have heart disease and diabetes, aged ≥ 40 years *

Notes: CS – total cholesterol; * – there are more complex versions of the scale, which take into account both the levels of LDL cholesterol and HDL cholesterol; all scale options and electronic calculators are available online - see www.escardio.org

Epidemiology

Hypertension is one of the most common chronic diseases. Hypertension is the most common chronic disease in the practice of a primary care physician (general practitioner - family doctor). Hypertension occurs in approximately one third of the population of most developed and developing countries. When analyzing the structure of hypertension by blood pressure levels, approximately 1/2 have grade 1 hypertension, 1/3 have grade 2 hypertension, and 1/6 have grade 3 hypertension. The prevalence of hypertension increases with age; at least 60% of people aged >60-65 years have elevated blood pressure or are receiving antihypertensive therapy. Among people aged 55-65 years, the probability of developing hypertension, according to the Framingham study, is more than 90%.

The World Health Organization considers hypertension as most important potentially preventable cause of death in the world .

Hypertension is associated with increased cardiovascular mortality and increased risk of cardiovascular complications in all age groups; among the elderly, the degree of this risk has a direct relationship with the level of systolic blood pressure (SBP) and an inverse relationship with the level of diastolic blood pressure (DBP).

There is also an independent association between the presence of hypertension, on the one hand, and the risk of developing heart failure, peripheral artery disease, and decreased renal function, on the other hand.

According to epidemiological data, in Western countries, approximately 50% of patients with hypertension do not know that they have high blood pressure (i.e., the diagnosis of hypertension has not been established); Among people with hypertension, only about 10% have blood pressure controlled within the target range.

Isolated systolic hypertension (ISAH) in the elderly

A number of world experts consider it as a separate pathological condition inherent in the elderly, associated with a decrease in the compliance of the arterial wall; with ISAH, SBP is increased and DBP is decreased (Table 1). An increase in SBP is an important pathophysiological factor contributing to the development of left ventricular hypertrophy; a decrease in DBP can lead to deterioration of coronary blood flow. The prevalence of ISAH increases with age; in elderly people this is the most common form of hypertension (up to 80-90% of all cases of hypertension).

In older people the presence of ISAH is associated with a more significant increase in cardiovascular risk than the presence of systolic-diastolic hypertension (with comparable SBP values).

To assess the degree of additional cardiovascular risk in ISAH, the same SBP levels, the same designations of risk factors, target organ damage and concomitant diseases should be used as in systolic-diastolic hypertension (Tables 1, 3, 4). It should be borne in mind that particularly low DBP levels (60–70 mmHg or lower) are associated with an additional increase in risk .

“White coat AG” (“AG in the doctor’s office”, “office AG”)

Diagnosed when BP measured in the doctor's office is ≥140/90 mmHg. in at least 3 cases, with normal blood pressure values ​​at home and according to ambulatory blood pressure monitoring (AMBP - see “Diagnostics of hypertension”). “White coat hypertension” is more common in older people and women. The cardiovascular risk in these patients is thought to be lower than that of patients with persistent hypertension (i.e., those with blood pressure levels that are above normal when measured at home and by ABPM), but is likely to be higher than that of normotensive individuals. Such individuals are recommended to make lifestyle changes, and in case of high cardiovascular risk and/or target organ damage, drug therapy (see section “Treatment of hypertension”).

Diagnostics of hypertension

Blood pressure levels are characterized by spontaneous variability during the day, as well as over longer periods of time (weeks-months).

The diagnosis of hypertension should usually be based on repeated blood pressure measurements. , performed under various circumstances; standard diagnosis of hypertension is provided based on data at least 2-3 visits to the doctor (during each visit, blood pressure should be increased for at least 2 measurements) .

If your blood pressure is only moderately elevated at your first visit to the doctor , then re-evaluation of blood pressure should be performed after a relatively longer period - after several months (if the blood pressure level corresponds to grade 1 hypertension - Table 1 and there is no damage to target organs).

In case if at the first visit the blood pressure level is increased more significantly (corresponds to grade 2 hypertension - Table 1) , or if there are possibly hypertension-related target organ lesions, or if the level of additional cardiovascular risk is high, then re-evaluation of blood pressure should be done after a relatively shorter time interval (weeks-days); if the blood pressure level at the first visit corresponds to stage 3 hypertension If there are clear symptoms of hypertension and the level of additional cardiovascular risk is high, then the diagnosis of hypertension can be based on data obtained during a single visit to the doctor.

Blood pressure measurement

Blood pressure measurement is recommended as standard mercury sphygmomanometer or aneroid manometer (the latter have become significant due to the trend towards eliminating mercury from widespread use). Regardless of the type, devices for measuring blood pressure must be in good working order , their performance should be periodically checked (when compared with data from other devices, usually mercury sphygmomanometers).

It is also possible to use semi-automatic devices for measuring blood pressure ; the accuracy of their work must be established using standard protocols; BP measurements should be periodically checked against data from mercury sphygmomanometers.

When measuring blood pressure, the following rules should be followed: · Provide the patient with the opportunity to sit for 3-5 minutes in a quiet environment before measuring blood pressure. The patient's legs should not be suspended. · In a sitting position, you need to take at least two blood pressure measurements, with a break between them lasting 1-2 minutes. If the obtained values ​​differ greatly (> 10 mm Hg), measure blood pressure a third time. The average value of the measurements taken should be taken into account. · In persons with arrhythmias (eg, atrial fibrillation), blood pressure should be measured several times to improve the accuracy of blood pressure assessment. · Typically, use a standard size inflation cuff (12-13 cm wide and 35 cm long). However, when measuring blood pressure in individuals with a larger (>32 cm) or smaller than normal upper arm circumference, it is necessary to use longer or shorter cuffs, respectively. · Regardless of the patient's body position, the pressure gauge should be located at the level of the heart. · When using the auscultatory measurement method, Korotkoff sounds I (first appearance of a clear tapping sound) and V (disappearance of the tapping sound) are used to assess systolic and diastolic blood pressure, respectively. · At the patient's first visit, blood pressure should be measured in both arms. The higher of the obtained values ​​should be taken into account. · *If the difference in blood pressure levels in the two arms is > 20 mm Hg, then you need to measure the blood pressure in both arms again. If the difference in blood pressure values ​​remains > 20 mm Hg. during repeat measurements, subsequent BP measurements should be performed on the arm where BP levels were higher. · In elderly people, in patients with diabetes, as well as in other situations where the presence of orthostatic hypotension can be assumed, blood pressure should be measured 1 and 3 minutes after standing up (with caution!). The presence of orthostatic hypotension (defined as a decrease in systolic blood pressure by ≥ 20 mm Hg or diastolic blood pressure by ≥ 10 mm Hg 3 minutes after standing) has been shown to be an independent cardiovascular risk factor. · After the second blood pressure measurement, the pulse rate should be assessed (by palpation, for 30 seconds).

Ambulatory blood pressure monitoring ( ABPM) compared with conventional blood pressure control. AMAD allows you to avoid possible measurement inaccuracies associated with violations of its methodology, device malfunction, and patient anxiety. This method also provides the ability to obtain multiple BP measurements over a 24-hour period without affecting the patient's emotional status. It is considered more reproducible than episodic measurement. AMAD data are less susceptible to the “white coat effect”.

Blood pressure levels recorded during ABPM are usually lower than those detected when measured in a doctor's office (Tables 6, 7).

Table 6. Determination of hypertension based on blood pressure measurements in the doctor's office and outside the doctor's office

Indications for AMAD include: 1) uncertainty about the diagnosis of hypertension, the assumption of the presence of a “white coat effect”; 2) the need to assess BP response to treatment, especially if office-based measurements consistently exceed target BP levels; 3) significant variability in data obtained when measuring blood pressure in a doctor’s office; 4) assumption of the presence of hypertension resistance to treatment; 5) assumption of the presence of episodes of hypotension.

Table 7. Principles of conducting AMAD

· ABPM is one of the most important research methods for individuals who are suspected of having hypertension (for its diagnosis), as well as for those whose diagnosis of hypertension has been established (for assessing the characteristics of hypertension and treatment tactics). · AMAD allows you to avoid possible measurement inaccuracies associated with violation of its methodology, device malfunction, or patient anxiety; considered more reproducible than episodic measurement; less susceptible to the “white coat effect”. · AMAD is performed using portable devices. The cuff is usually placed on the shoulder of the non-dominant arm. The duration of AMAD is 24-25 hours (covers periods of wakefulness and sleep) · The initial blood pressure level measured by the ABPM device should not differ from what was previously measured with a conventional pressure gauge by more than 5 mmHg. Otherwise, the AMAD cuff must be removed and put on again. · The patient is instructed to maintain his usual activity schedule, but to refrain from excessive exercise. During the period of air inflation into the cuff, it is recommended to refrain from movements and conversation, to keep the shoulder as motionless as possible and at the level of the heart. · During AMBP, the patient should keep a diary, which records the time of taking medications, eating, waking up and falling asleep, and also noting any symptoms that may be associated with changes in blood pressure. · With ABPM, blood pressure measurements are usually taken every 15 minutes during the day and every 30 minutes at night (other options are possible, for example, every 20 minutes, regardless of the time of day). Significant interruptions in measurements should be avoided. In computer analysis, at least 70% of all measurements must be of adequate quality. · When interpreting ABPM results, the data of average daily, average daily and average night blood pressure should first be taken into account. Blood pressure measurement data for shorter periods of time, as well as more complex indicators (ratios, indices), are of less importance. · It is important to assess the ratio of average night / average day blood pressure. Normally, blood pressure decreases at night; persons having such a decrease (“dipping”) are designated as “dippers” (with levels of this ratio in the range of 0.8-0.9). Those who do not show physiological BP reduction at night (at a ratio > 1.0 or, to a lesser extent, 0.9-1.0) show a higher incidence of cardiovascular events compared with those who have adequate nocturnal BP reduction. Some authors also identify a category of people with an excessive nocturnal decrease in blood pressure (ratio ≤ 0.8), however, the prognostic significance of this phenomenon needs to be clarified.

Home blood pressure monitoring (HABP): advantages and modern concepts (Table 8) . This method is becoming more common, especially with the increasing use of semi-automatic blood pressure machines.

Table 8. Principles of MADD

· Data obtained from MADD are of great importance for the diagnosis of hypertension (Table 6), assessment of its features and prognosis. Thus, MABP results correlate better with target organ damage, as well as with cardiovascular prognosis, than BP levels obtained when measured in a doctor's office. Data are presented that, when performed correctly, MABP results have the same high prognostic significance as AMBP data. · Blood pressure should be measured daily for at least 3-4 consecutive days (preferably for 7 consecutive days) - in the morning and evening. Blood pressure is measured in a quiet room, after 5 minutes of rest, with the patient sitting (the back and shoulder on which blood pressure is measured must be supported). · 2 blood pressure measurements are performed with a 1-2 minute break between them. · Results should be recorded on a standard form immediately after measurement. · The MADD result is the average of all measurements, with the exception of the readings obtained on day 1. · A physician should interpret MADD results. · Most patients with hypertension (in the absence of cognitive impairment and physical limitations) should be trained in self-monitoring of blood pressure. Self-monitoring of blood pressure may not be indicated in persons with excessive anxiety and phobias (where ABPM is more preferable), with a very large upper arm circumference, with significant pulse irregularity (for example, with atrial fibrillation), with a very pronounced increase in the stiffness of the vascular wall (all available for portable semi-automatic devices for measuring blood pressure use an oscillometric method, which may distort the results in such patients).

Examination of patients with hypertension

Examination of patients with hypertension (including medical history - Table 9, parts 1 and 2; objective examination - Table 10; as well as laboratory and instrumental studies - Table 11) should be aimed at searching for:

• factors provoking hypertension;
• target organ damage;
• data on the presence of symptomatic hypertension;
• clinical manifestations of cardiovascular complications (chronic heart failure, cerebrovascular and peripheral vascular complications, etc.);
• concomitant diseases/conditions (diabetes mellitus, atrial fibrillation, cognitive impairment, frequent falls, unsteadiness when walking, etc.) that may affect the choice of treatment tactics.

Table 9. Features of collecting anamnesis in patients with hypertension (part 1)

Determining the period of time during which the patient knows about an increase in blood pressure (including according to self-measurement data)

Search for possible causes of symptomatic hypertension: 1. Family history of CKD (eg, polycystic kidney disease) 2. History data on the presence of CKD (including episodes of dysuria, gross hematuria), abuse of analgesics, NSAIDs 3. Taking medications that can increase blood pressure (oral contraceptives, vasoconstrictor nasal drops, gluco- and mineralocorticoids, NSAIDs, erythropoietin, cyclosporine) 4. Taking amphetamines, caffeine, licorice (licorice) 5. Episodes of sweating, headaches, anxiety, palpitations (pheochromocytoma) 6. Episodes of muscle weakness and cramps (hyperaldosteronism) 7. Symptoms suggesting the possibility of thyroid dysfunction

Assessment of cardiovascular risk factors: 1. Personal or family history of hypertension, cardiovascular diseases, dyslipidemia, diabetes mellitus (polyuria, glucose levels, antihyperglycemic drugs) 2. Smoking 3. Dietary habits (table salt, liquid) 4. Body weight, its recent dynamics. Obesity 5. Amount of physical activity 6. Snoring, breathing disorders during sleep (including from the words of a partner) 7. Low birth weight 8. For women – history of preeclampsia during pregnancy

Note: NSAIDs – non-steroidal anti-inflammatory drugs

Table 9. Features of collecting anamnesis in patients with hypertension (part 2)

Data on target organ damage and cardiovascular diseases: 1. Brain and eyes: headache, dizziness, visual impairment, motor impairment, sensory impairment, previous transient ischemic attack/stroke, carotid revascularization procedures. 2. Heart: chest pain, shortness of breath, swelling, syncope, palpitations, rhythm disturbances (especially atrial fibrillation), previous myocardial infarction, coronary revascularization procedures. 3. Kidneys: thirst, polyuria, nocturia, gross hematuria. 4. Peripheral arteries: coldness of the extremities, intermittent claudication, pain-free walking distance, previous peripheral revascularization procedures. 5. Snoring / chronic lung disease / sleep apnea. 6. Cognitive dysfunction.

Data on the treatment of hypertension: 1. Antihypertensive drugs currently available. 2. Antihypertensive drugs in the past. 3. Data on adherence and non-adherence to treatment. 4. Efficacy and side effects of drugs.

Table 10. Features of an objective study of patients with hypertension
(search for symptomatic hypertension, target organ damage, obesity)

Search for symptomatic hypertension: 1. During examination, identification of features typical of Cushing’s syndrome. 2. Skin signs of neurofibromatosis (pheochromocytoma). 3. Palpation of enlarged kidneys (polycystic disease). 4. Auscultation of the abdomen reveals murmurs over the projections of the renal arteries (renovascular hypertension). 5. During auscultation of the heart and projections of large vessels - noises characteristic of coarctation of the aorta, other lesions of the aorta (dissection, aneurysm), lesions of the arteries of the upper extremities. 6. Weakening of the pulse and a decrease in pressure on the femoral arteries compared to that on the brachial arteries (coarctation of the aorta, other lesions of the aorta (dissection, aneurysms), lesions of the arteries of the lower extremities). 7. Significant difference in blood pressure levels measured on the right and left brachial arteries – > 20 mm Hg. systolic blood pressure and/or > 10 mm Hg. diastolic blood pressure (coarctation of the aorta, stenosis of the subclavian artery).

Search for target organ lesions: 1. Brain: movement disorders, sensory disturbances. 2. Retina: disorders in the fundus. 3. Heart: heart rate, apical impulse, boundaries of relative cardiac dullness, 3rd and 4th heart sounds, murmurs, rhythm disturbances, wheezing in the lungs, peripheral edema. 4. Peripheral arteries: absence, decrease or asymmetry of pulse, cold extremities, ischemic skin changes. 5. Carotid arteries: systolic murmurs.

Obesity assessment: 1. Height and weight. 2. Calculation of body mass index: weight / height 2 (kg/m2). 3. Waist circumference is measured in a standing position at the level midway between the lower edge of the costal arch and the iliac crest.

Table 11. Laboratory and instrumental studies for hypertension

Routine studies:
1. General blood test 2. Fasting plasma glucose 3. Total cholesterol, serum low- and high-density lipoproteins 4. Serum triglycerides	5. Serum sodium and potassium 6. Serum uric acid 7. Serum creatinine, glomerular filtration rate calculation 8. Urinalysis, microalbuminuria test 9. 12-lead ECG
Additional studies (taking into account medical history, objective examination and results of routine studies):
1. Glycosylated hemoglobin (if plasma glucose > 5.6 mmol/l and in persons with diabetes mellitus) 2. Urine sodium and potassium 3. AMAD and MADD 4. Echocardiography 5. Holter ECG monitoring 6. Stress tests to detect coronary ischemia	7. Ultrasound examination of the carotid arteries 8. Ultrasound examination of peripheral arteries, abdominal organs 9. Estimation of pulse wave propagation speed 10. Determination of the ankle-brachial index 11. Fundus examination
Research conducted under conditions specialized assistance:
1. Further search for brain, cardiac, renal and vascular lesions (with resistant and complicated hypertension) 2. Search for the causes of symptomatic hypertension, which are suspected based on the history, objective examination and previous examinations

Treatment of hypertension

Beneficial effects of blood pressure control within target levels in people with hypertension (according to RCTs and meta-analyses).

A decrease in cardiovascular mortality and the incidence of cardiovascular complications and a less pronounced effect on overall mortality have been shown. There is also a clear reduction in the risk of developing chronic heart failure.

The reduction in the risk of strokes during antihypertensive therapy is more pronounced than the reduction in the risk of coronary complications. Thus, a decrease in diastolic blood pressure by only 5-6 mm Hg. leads to a reduction in the risk of stroke over 5 years by approximately 40%, and coronary heart disease by approximately 15%.

The more pronounced the degree of blood pressure reduction (within target levels), the higher the beneficial effect on the prognosis.

The listed beneficial effects are also shown in elderly people, incl. in those with isolated systolic hypertension. Beneficial effects were noted in patients of different ethnic groups (white, black, Asian populations, etc.).

Goals of hypertension treatment. The main goal of treatment for hypertension is reduction in cardiovascular risk, reduction in the risk of developing CHF and chronic renal failure . The beneficial effects of treatment must be weighed against the risks associated with possible treatment complications. In treatment tactics, it is important to include measures aimed at correcting potentially correctable cardiovascular risk factors identified in the patient, including smoking, dyslipidemia, abdominal obesity, and diabetes mellitus.

Target blood pressure levels recommended by experts in Europe and the USA during antihypertensive therapy are presented in Table. 12. For the category of elderly patients with hypertension, it is important to keep in mind that their blood pressure levels usually vary more significantly; that they are more prone to developing episodes of hypotension (including orthostatic, postural hypotension). The choice of target blood pressure level for a particular patient should be individual.

Table 12. Target blood pressure levels for patients with hypertension

	Target blood pressure
Uncomplicated hypertension
Hypertension in combination with coronary artery disease (including in post-infarction patients)
Hypertension after stroke
Hypertension in combination with peripheral arterial lesions
Hypertension in combination with CKD (with proteinuria< 0,15 г/л)
Hypertension in combination with CKD (with proteinuria ≥ 0.15 g/l)
Hypertension in combination with diabetes mellitus type 1 and 2
Hypertension in pregnant women
Hypertension in patients aged 65 years and older	Systolic 140 – 150
Hypertension in frail elderly people	At the discretion of the doctor

Note. * – at low levels of “evidence base”.

Non-pharmacological treatment

The following lifestyle changes can help lower blood pressure and reduce cardiovascular risk:

• Weight loss for obese patients (if body mass index is more than 30 kg/m2). It has been shown that in such patients, a persistent decrease in body weight by 1 kg is accompanied by a decrease in systolic blood pressure by 1.5-3 mm Hg, diastolic blood pressure by 1-2 mm Hg.
• Regular physical activity outdoors (for a hemodynamically stable patient - at least 150 (or better - at least 300) minutes per week; for many patients, brisk walking for 30-45 minutes daily or at least 5 times a week is sufficient). Isometric loads (for example, lifting weights) contribute to an increase in blood pressure; it is advisable to avoid them.
• Reducing salt intake . It has been shown that a decrease in salt intake to 5.0 g/day (as much as it is contained in 1/2 teaspoon) is associated with a decrease in systolic blood pressure by 4-6 mm Hg, diastolic blood pressure by 2-3 mm Hg. . The decrease in blood pressure due to decreased salt intake is more pronounced in older people. As a fairly effective measure (helping to reduce salt intake by about 30%), the recommendation to remove the salt shaker from the table can be used.
• Reduce alcohol consumption.
• Reducing your intake of saturated fats (fat of animal origin).
• Increasing consumption of fresh fruits and vegetables (in total, about 300 g/day is desirable),
• Stop smoking .

Pharmacological treatment

Pharmacological treatment (Table 13) required by most patients with hypertension , the main goal of this treatment is to improve cardiovascular prognosis.

Table 13. General issues of pharmacological treatment for hypertension

Drug therapy for hypertension (in combination with non-drug treatment approaches) with stable maintenance of blood pressure levels within target values ​​contributes to significant improvement of cardiovascular (with a reduction in the risk of fatal and non-fatal cerebral strokes and myocardial infarction), as well as renal prognosis (with a decrease in the rate of progression of renal lesions).

Treatment (non-drug and medicinal) must be started as early as possible and carried out continuously, usually throughout life. The concept of “course treatment” is not applicable to antihypertensive therapy.

· Elderly In patients with hypertension, drug antihypertensive therapy is recommended to begin when systolic blood pressure levels are ≥ 160 mmHg. (I/A). Antihypertensive drugs can be prescribed to older adults under 80 years of age and with systolic blood pressure levels between 140-159 mmHg if well tolerated (IIb/C) It is not recommended to initiate antihypertensive therapy until further data are available. persons with high normal blood pressure – 130-139 / 85-89 mmHg. (III/A). This recommendation primarily applies to individuals who do not have concomitant cardiovascular lesions.

Most often used in the treatment of patients with hypertension 5 classes of antihypertensive drugs : diuretics, calcium channel blockers, ACE inhibitors, sartans, beta-blockers. For drugs in these classes, there are large studies demonstrating their beneficial effects on prognosis. Other classes of antihypertensive drugs (related to the “second line”) may also be used.

Widespread (helps to increase the effectiveness and safety of treatment). Justified use fixed combination drugs (improves patient “adherence”).

Preference is given to antihypertensive drugs extended action ( incl. retard forms).

After prescribing antihypertensive therapy, the doctor should examine the patient no later than 2 weeks . If the reduction in blood pressure is insufficient, the dose of the drug should be increased, or the drug should be changed, or an additional drug of a different pharmacological class should be prescribed. In the future, the patient should Check regularly (every 1-2 weeks) until satisfactory blood pressure control is achieved . After stabilization of blood pressure, the patient should be examined every 3-6 months (with satisfactory health).

It is shown that the use of antihypertensive drugs in patients with hypertension both under 80 and ≥80 years of age is accompanied by an improvement in cardiovascular prognosis. Adequate pharmacological treatment of hypertension does not have an adverse effect on cognitive function in elderly patients, does not increase the risk of developing dementia; Moreover, it can probably reduce such a risk.

Treatment must begin from small doses , which can be gradually increased if necessary. It is highly desirable to choose drugs with daily duration of action .

Tables 14–17 present the classifications of the various classes of antihypertensive drugs; The place of sartans is discussed in more detail below.

Table 14. Diuretics in the treatment of hypertension (adapted from ISH/ASH, 2013)

Name	Doses (mg/day)		Frequency of reception
Thiazide:
Hydrochlorothiazide*
Bendroflumethiazide
Thiazide-like:
Indapamide
Chlorthalidone
Metolazone
Loop:
Furosemide	20 mg 1 time / day	40 mg 2 times a day #
Torasemide
Bumetanide
Potassium-sparing:
Spironolactone**
Eplerenone**
Amiloride
Triamterene

Notes: * – part of the fixed combination of telmisartan with hydrochlorothiazide; ** – refer to mineralocorticoid receptor antagonists (aldosterone antagonists); # – with reduced kidney function, higher doses may be required.

Table 15. Calcium channel blockers (calcium antagonists) for hypertension (adapted from ISH/ASH, 2013)

Name	Doses (mg/day)		Frequency of reception
Dihydropyridine:
Amlodipine*
Isradipin	2.5 2 times per day	5-10 2 times per day
Lacidipine
Lercanidipine
Nifedipine extended validity
Nitrendipine
Felodipin
Non-dihydropyridine (heart rate**-lowering):
Verapamil
Diltiazem

Notes: * – included in the fixed combination of telmisartan and amlodipine;
** – HR – heart rate.

Table 16. ACE inhibitors for hypertension (adapted from ISH/ASH, 2013)

Table 17. β-blockers for hypertension (adapted from ISH/ASH, 2013)

Name	Doses (mg/day)		Frequency of reception
Atenolol*
Betaxolol
Bisoprolol
Carvedilol	At 3.125 2 r/s	6.25-25 2 times per day
Labetalol
Metoprolol succinate
Metoprolol tartrate		50-100 2 r/s
Nebivolol
Propranolol		For 40-160 2 r/s

Note: * – currently there is a clear tendency to reduce the use of atenolol in the treatment of hypertension and coronary heart disease.

Place of sartans (angiotensin receptor antagonists)II)

in the treatment of hypertension

In the Expert Guidelines ESC / ESH - 2013, ASH / ISH - 2013 and JNC-8 - 2014, sartans are considered as one of the main, most commonly used classes of antihypertensive drugs. Further in the text, as well as in tables 18–19, the main data concerning this class of drugs, which are given in the global Recommendations we are discussing, are presented.

Table 18 shows the dosage and frequency of use of sartans for hypertension.

Table 18. Sartans in the treatment of hypertension (adapted from ISH/ASH, 2013)

Some pharmacological features of sartans are presented in Table 19.

Table 19. Some pharmacological features of sartans (adapted from Kaplan NM, Victor RG, 2010)

Drug *	Half-life, h	Active metabolite	Effect of food intake on absorption	Path excretion	Additional properties
Azisartan				Kidneys – 42%, liver – 55%
Valsartan				Kidneys – 30%, liver – 70%
Irbesartan				Kidneys – 20%, liver – 80%	Weak PPARγ receptor agonist**
Candesartan				Kidneys – 60%, liver – 40%
Losartan				Kidneys – 60%, liver – 40%	Uricosuric
Olmesartan				Kidneys – 10%, liver -90%
Telmisartan				Kidneys – 2%, liver – 98%	PPARγ receptor agonist**
Eprosartan				Kidneys – 30%, liver – 70%	Sympatholytic

Notes: * – for all sartans there are fixed combinations with thiazide/thiazide-like diuretics; ** - the effect on peroxisome proliferator-activated receptor-γ is stronger with telmisartan, less pronounced with irbesartan - provides additional beneficial effects on the metabolism of glucose and lipids.

Sartans, like ACE inhibitors, counteract the renin-angiotensin system. They lower blood pressure by blocking the action of angiotensin II on its AT1 receptor, and thereby block the vasoconstrictor effect of these receptors.

Sartans are well tolerated. They do not cause cough development; when using them, angioedema rarely occurs; their effects and benefits are similar to those of ACE inhibitors. Therefore, as a rule, their use is preferable to the use of ACE inhibitors. Like ACE inhibitors, sartans can increase serum creatinine levels by up to 30%, mainly due to a decrease in glomerular pressure and a decrease in glomerular filtration rate. These changes, usually functional, are reversible (transient) and are not associated with long-term decline in kidney function (considered harmless).

Sartans do not have dose-dependent side effects, which makes it possible to use average or even maximum approved doses at the initial stage of treatment (i.e., does not require titration).

Sartans have the same beneficial effects on cardiovascular and renal prognosis as ACE inhibitors.

Like ACE inhibitors, sartans have a more pronounced antihypertensive (and organoprotective) effect in white and Asian patients; less pronounced in black patients, however, when using sartans in combination with any calcium channel blocker or diuretic, the treatment effect becomes independent of race.

There is a unanimous recommendation not to use a combination of sartans with ACE inhibitors; Each of these drugs has beneficial renoprotective effects, but in combination they may have a negative effect on renal prognosis.

When initiating the use of sartans in individuals already taking diuretics, it may be beneficial to skip the diuretic dose to prevent a sharp decrease in blood pressure.

Sartans should not be used in pregnant women, especially in the 2nd and 3rd trimesters, as they may jeopardize the normal development of the fetus.

Possibilities of telmisartan

(including fixed combinations

with hydrochlorothiazide and amlodipine).

Telmisartan is one of the most studied and effective representatives of the sartan class, it is characterized by a powerful and stable antihypertensive effect, the presence of a complex of organoprotective and beneficial metabolic effects, a high level of “evidence base” for a positive effect on cardiovascular, cerebrovascular and renal prognosis, obtained in the largest randomized controlled trials. More detailed characteristics of telmisartan are presented in Table 20.

It is necessary to pay attention to the presence of two options for fixed combinations of the original telmisartan - a combination with hydrochlorothiazide (tablets of 40/12.5 mg and 80.12.5 mg - Table 20) and a combination with amlodipine (tablets of 80/5 mg and 80/10 mg – table 21). Taking into account the priority that is now given to combination antihypertensive therapy (see below), their use can be considered as one of the important components of the daily management of hypertension.

Table 20. General characteristics of telmisartan and the fixed combination of telmisartan with hydrochlorothiazide – 1 part

· Telmisartan (80 mg tablets), a fixed combination of telmisartan with hydrochlorothiazide is also presented, consisting of 40 and 12.5 mg per tablet, respectively, as well as 80 and 12.5 mg per tablet. · Telmisartan is a representative of one of the 5 main classes of antihypertensive drugs. It is also used in the treatment of patients with chronic ischemic heart disease, diabetes mellitus, and chronic kidney disease. · It is one of the most studied representatives of the sartan class. It has an authoritative “evidence base” on the positive effect on cardiovascular, cerebrovascular and renal prognosis (ONTARGET / TRANSCEND / PROFESS program, etc.). · The positive metabolic effects of telmisartan have been proven (with a decrease in insulin resistance, a decrease in glycemic levels, glycosylated hemoglobin, low-density lipoprotein cholesterol, triglycerides). This allows it to be widely used in people with diabetes mellitus, prediabetes, metabolic syndrome, and obesity. · Extensive safety data are available for telmisartan. It does not cause cough (unlike ACE inhibitors). To the same extent as ACE inhibitors, it reduces the risk of myocardial infarction in individuals with increased cardiovascular risk. Does not increase the risk of developing cancer. The drug is not used in pregnant and lactating women. It should not be combined with ACE inhibitors.

Telmisartan selectively inhibits the binding of angiotensin II (AII) to type 1 receptors (AT1) on target cells. In this case, all known effects of AII on these receptors are blocked (including vasoconstrictor, aldosterone-secreting, etc.). · When used, the levels of plasma aldosterone, C-reactive protein and pro-inflammatory cytokines are reduced. · The half-life is the most significant in comparison with other sartans, it ranges from 20 to 30 hours. The maximum concentration in plasma is achieved 1 hour after administration, a clear antihypertensive effect is achieved after 3 hours. Metabolized in the liver; in this regard, it is highly safe in patients with reduced renal function. · Application – regardless of food intake. The initial dose is 20-40 mg/day for 1 dose, if necessary – up to 80 mg/day. In persons with decreased liver function, the daily dose is no more than 40 mg.

Table 20. General characteristics of telmisartan and the fixed combination of telmisartan with hydrochlorothiazide - part 2

· Antihypertensive effects of telmisartan well studied. Shown: 1) a high percentage of “responders” when using a dose of 80 mg/day - with the achievement of target blood pressure values, according to daily monitoring, among people with hypertension in general - up to 69-81%; 2) smoothness and stability of blood pressure reduction, reaching the maximum of this effect approximately 8-10 weeks from the start of use; 3) preservation of the antihypertensive effect for 24 hours with a single dose per day; 4) excellent protection against increases in blood pressure in the early morning hours (which is often the direct cause of the development of cardiovascular complications in people with hypertension); 5) absence of tachyphylaxis (decreased severity of antihypertensive effect) with many months of use; 5) absence of “withdrawal syndrome”; 6) an additional significant increase in the antihypertensive effect when combined with hydrochlorothiazide; 7) placebo-like tolerability. · Presents evidence of diverse organ-protective effect of telmisartan : 1) regression of left ventricular hypertrophy; 2) reduction of arterial stiffness and endothelial dysfunction; 3) reduction of microalbuminuria and proteinuria in patients with hypertension and type 2 diabetes mellitus. · Confirmed effectiveness, excellent tolerability, organ protection and high adherence of patients to treatment motivate the possibility of using telmisartan drugs and a fixed combination of telmisartan with hydrochlorothiazide in a wide range of patients with hypertension . The use of these drugs is justified in people with hypertension, regardless of gender and age, including both patients with uncomplicated hypertension and people with a combination of hypertension with metabolic syndrome, hyperlipidemia, obesity, diabetes mellitus (type 1 or 2), chronic ischemic heart disease, chronic kidney diseases (both diabetic and non-diabetic), as well as post-stroke patients with hypertension.

Table 21. Characteristics of the original fixed combination of telmisartan (80 mg) and amlodipine (5 mg or 10 mg) – 1 part

General characteristics: · Each of the components of this combination is a representative of one of the most commonly used classes of antihypertensive drugs: telmisartan - an angiotensin II receptor antagonist; amlodipine is a calcium channel blocker. · The combination of sartan with a calcium channel blocker is justified from a pathophysiological and clinical point of view (e.g. mutual enhancement of the antihypertensive effect, reducing the risk of developing edema in response to amlodipine ). This combination in modern (2013-2014) recommendations is considered as one of the most preferred . Similar combinations have been successfully used in largest studies

Characteristics of fixed combination components Telmisartan and amlodipine: · Detailed characteristics telmisartan given in table 20 · Amlodipine – 3rd generation dihydropyridine calcium channel blocker, one of the most prescribed antihypertensive and antianginal drugs in the world. · Does not have adverse effects on lipid profile and glycemia. · Has the longest half-life among drugs of its class (30-50 hours), which provides it with: 1) a gradual and smooth onset of action; 2) long-term and stable antihypertensive and antianginal effect; 3) the possibility of taking 1 time per day; 4) high adherence of patients to treatment; 5) no risk of increased blood pressure and increased angina if the patient accidentally skips taking the drug. · Maximum plasma concentration is achieved 6-12 hours after oral administration (as a result of which clear antihypertensive and antianginal effects develop within 6 hours after the first dose). A stable concentration equilibrium occurs by 7-8 days from the start of administration (the clinical effects of the drug at the beginning of therapy can gradually increase day by day and stabilize by 7-8 days). · Take regardless of meals. · The drug provides coronary vasodilation confirmed in large studies (significant antianginal effects - CAPE II, clear antiatherosclerotic effects (PREVENT, NORMALIZE); improved prognosis in chronic ischemic heart disease (PREVENT, CAMELOT). · In a number of authoritative studies, amlodipine demonstrated a clear antihypertensive effect, improvement in the daily blood pressure profile, a favorable effect on the prognosis of hypertension (including renal and cerebrovascular) and excellent tolerability (ALLHAT, VALUE, ASCOT).

Table 21. Characteristics of the original fixed combination of telmisartan (80 mg) and amlodipine (5 mg or 10 mg) – part 2

Possibility of using a fixed combination Telmisartan and amlodipine for hypertension: · Can be widely used in the treatment of hypertension: 1) regardless of gender and age; 2) as initial therapy or when previous antihypertensive regimens are insufficiently effective; 3) as a single antihypertensive approach or as part of multicomponent combinations. · Used in the following categories of patients with hypertension: Ø with uncomplicated essential hypertension (hypertension); Ø for hypertension in the elderly (including individuals with isolated systolic hypertension, as well as patients with various concomitant conditions); Ø for hypertension in patients with chronic coronary heart disease (both in the presence of anginal syndrome and in its absence; regardless of previous myocardial infarctions and coronary revascularization procedures; in combination with other standard treatment approaches - statins, antithrombotics); Ø for hypertension in persons with diabetes mellitus, metabolic syndrome, hyperlipidemia, obesity; Ø for hypertension in combination with chronic kidney disease - CKD (including as a renoprotective approach; used up to stage 5 CKD inclusive; in persons with CKD stages 3-5, dose reduction is not required); Ø for hypertension in patients with chronic obstructive pulmonary disease; Ø for hypertension in post-stroke patients, in persons with peripheral vascular diseases. · Usual use: 1 tablet 1 time per day, regardless of meals. Caution is required in persons with reduced liver function. · The drug should not be used during pregnancy and breastfeeding.

Choice of treatment tactics:

monotherapy or combination antihypertensive therapy?

Figures 2 and 3 present approaches to the choice of treatment tactics for hypertension, recommended, respectively, by experts in Europe, 2013 and the USA, 2013.

Figure 2. Approaches to the choice of monotherapy or combination therapy for hypertension ESC-ESH, 2013

Figure 3. Approaches to choosing treatment tactics for hypertension, USA, 2013

Note: TD – thiazide diuretic; CHF – chronic heart failure; DM – diabetes mellitus; CKD is a chronic kidney disease.

Many patients can be prescribed combination antihypertensive therapy two drugs. Figure 4 shows the combinations of antihypertensive drugs recommended by ESC-ESH experts in 2013. If necessary, use three-component antihypertensive therapy (usually a calcium channel blocker + thiazide diuretic + ACE inhibitor / sartan). It is not recommended to combine an ACE inhibitor with sartan.

If a patient has a high or very high level of additional cardiovascular risk, the treatment strategy should include statin (for example, atorvastatin at a dose of 10 mg/day; in the presence of concomitant ischemic heart disease, the dose should be higher) and aspirin (75-100 mg/day, after achieving blood pressure control, after meals in the evening) - if tolerated and there are no contraindications, for continuous use. The main purpose of prescribing a statin and aspirin in this case is to reduce the risk of cardiovascular complications.

Figure 4. Combinations of antihypertensive drugs

Note: Combinations indicated green solid line (letter “a” ), are preferable (rational); green broken line (letter " b ») – also rational, but with some restrictions; black intermittent (letter “c”) – possible, but less studied; red line (letter " d ») Not recommended combination is marked.

Conclusion. Summarizing the results presented, it can be noted that: 1) when choosing a treatment strategy in patients with hypertension, a general practitioner, family doctor and cardiologist should focus on the target blood pressure levels presented in the new world Recommendations, as well as approaches to the selection of certain classes of antihypertensive drugs ; 2) among the classes of antihypertensive drugs, sartans deserve more attention (than has traditionally been the case among most practicing clinicians) - highly effective and safe drugs with favorable diverse organoprotective effects and a positive effect on prognosis; 3) Telmisartan (both alone and in the form of fixed combinations with hydrochlorothiazide or amlodipine) may be a good choice for antihypertensive energizing agent in many patients with hypertension .

Conventional abbreviations:

AG – arterial hypertension

BP - blood pressure

ACE – angiotensin-converting enzyme

CCBs – calcium channel blockers

β-AB – β-blockers

ABPM – 24-hour blood pressure monitoring

GFR – glomerular filtration rate

CKD – chronic kidney disease

REFERENCES:

1. Sirenko Yu. N. Hypertension and arterial hypertension / Yu. N. Sirenko. – Donetsk: Zaslavsky Publishing House, 2011. – 352 p.
2. AHA/ACC Guideline on lifestyle management to reduce cardiovascular risk [Electronic resource] / R.H. Eckel, J.M. Jakicic, J.D. Ard // Circulation. – 2013. – 46 rub. – Journal access mode: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437740.48606.d1. full.pdf.
3. Campos-Outcalt D. The new cardiovascular disease prevention guidelines: what you need to know / D. Campos-Outcalt // J. Fam. Pract. – 2014. – Vol. 63, no. – P. 89-93.
4. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension [Electronic resource] / M.A. Weber, E.L. Schiffrin, W.B. White // J. Clin. Hypertens. – 2013. – Journal access mode: http://www.ash-us.org/documents/ASH_ISH-Guidelinespdf.
5. ESH/ESC Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) / G. Mancia, R. Fagard, K. Narkiewicz // J. Hypertens. – 2013. – Vol. 31. – P.1281–1357.
6. Evidence-Based guideline for the management of high blood pressure in adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) [Electronic resource] / R.A. James, S. Oparil, B.L. Carter//Amer. Med. Ass. – 2014. – Journal access mode: http://circ.ahajournals.org/content/124/18/2020.full .
7. Ruilope L. M. Long-term adherence to therapy: the clue to prevent hypertension consequences / L. M. Ruilope // Eur. Heart J. – 2013. – Vol.34. – P.2931-2932.

Hypertension or other types of arterial hypertension significantly increases the likelihood of stroke, heart attack, vascular disease and chronic kidney disease. Because of its morbidity, mortality, and costs to society, the prevention and treatment of hypertension is an important public health issue. Fortunately, recent advances and research in this area have led to an improved understanding of the pathophysiology of hypertension and the development of new pharmacological and interventional treatments for this common disease.

Development mechanisms

Why hypertension occurs is still unclear. The mechanism of its development has many factors and is very complex. It involves various chemicals, vascular reactivity and tone, blood viscosity, the functioning of the heart and nervous system. A genetic predisposition to the development of hypertension is assumed. One of the modern hypotheses is the idea of ​​immune disorders in the body. Immune cells infiltrate target organs (vessels, kidneys) and cause persistent disruption of their functioning. This has been noted, in particular, in persons with HIV infection and in patients who have been taking immunosuppressants for a long time.

Labile arterial hypertension usually develops initially. It is accompanied by instability of pressure numbers, increased heart function, and increased vascular tone. This is the first stage of the disease. At this time, diastolic hypertension is often recorded - an increase in only the lower pressure figure. This happens especially often in young women with excess body weight and is associated with swelling of the vascular wall and increased peripheral resistance.

Subsequently, the increase in pressure becomes permanent, affecting the aorta, heart, kidneys, retina and brain. The second stage of the disease begins. The third stage is characterized by the development of complications from the affected organs - myocardial infarction, renal failure, visual impairment, stroke and other serious conditions. Therefore, even labile arterial hypertension requires timely detection and treatment.

The progression of hypertension usually looks like this:

• transient arterial hypertension (temporary, only during stress or hormonal imbalances) in people 10–30 years old, accompanied by an increase in blood output from the heart;
• early, often labile arterial hypertension in people under 40 years of age, who already have an increase in resistance to blood flow in small vessels;
• disease with target organ damage in persons 30–50 years old;
• addition of complications in the elderly; At this time, after a heart attack, the heart muscle weakens, heart function and cardiac output decrease, and blood pressure often decreases - this condition is called “decapitated hypertension” and is a sign of heart failure.

The development of the disease is closely related to hormonal disorders in the body, primarily in the renin-angiotensin-aldosterone system, which is responsible for the amount of water in the body and vascular tone.

Causes of the disease

Essential hypertension, which accounts for up to 95% of cases of all hypertension, occurs under the influence of external unfavorable factors in combination with genetic predisposition. However, the specific genetic abnormalities responsible for the development of the disease have never been identified. Of course, there are exceptions when a disruption in the functioning of one gene leads to the development of pathology - this is Liddle syndrome, some types of adrenal pathology.

Secondary arterial hypertension can be a symptom of various diseases.

Renal causes account for up to 6% of all cases of hypertension and include damage to the tissue (parenchyma) and blood vessels of the kidneys. Renoparenchymal arterial hypertension can occur with the following diseases:

• polycystic disease;
• chronic kidney disease;
• Liddle's syndrome;
• compression of the urinary tract by a stone or tumor;
• a tumor that secretes renin, a powerful vasoconstrictor.

Renovascular hypertension is associated with damage to the vessels supplying the kidneys:

• coarctation of the aorta;
• vasculitis;
• narrowing of the renal artery;
• collagenoses.

Endocrine arterial hypertension is less common - up to 2% of cases. They can be caused by taking certain medications, such as anabolic steroids, oral contraceptives, prednisolone, or non-steroidal anti-inflammatory drugs. Alcohol, cocaine, caffeine, nicotine and licorice root preparations also increase blood pressure.

Increased pressure is accompanied by many diseases of the adrenal glands: pheochromocytoma, increased production of aldosterone and others.

There is a group of hypertension associated with brain tumors, polio, or high intracranial pressure.

Finally, do not forget about these rarer causes of the disease:

• hyperthyroidism and hypothyroidism;
• hypercalcemia;
• hyperparathyroidism;
• acromegaly;
• obstructive sleep apnea syndrome;
• gestational hypertension.

Obstructive sleep apnea syndrome is a common cause of high blood pressure. Clinically, it is manifested by periodic cessation of breathing during sleep due to snoring and the appearance of obstructions in the airways. About half of these patients have high blood pressure. Treatment of this syndrome allows normalizing hemodynamic parameters and improving the prognosis of patients.

Definition and classification

Types of blood pressure - systolic (develops in the vessels at the time of systole, that is, contraction of the heart) and diastolic (preserved in the vascular bed due to its tone during myocardial relaxation).

The classification system is important for deciding the aggressiveness of treatment or therapeutic interventions.

Arterial hypertension is an increase in blood pressure to 140/90 mm Hg. Art. and higher. Often both of these numbers increase, which is called systole-diastolic hypertension.

In addition, blood pressure due to hypertension may be normal in people receiving chronic antihypertensive medications. The diagnosis in this case is clear based on the history of the disease.

Prehypertension is considered to be a blood pressure level of up to 139/89 mm Hg. Art.

Degrees of arterial hypertension:

• first: up to 159/99 mm Hg. Art.;
• second: from 160/from 100 mm Hg. Art.

This division is to a certain extent arbitrary, since the same patient has different pressure readings under different conditions.

The classification given is based on the average of 2 or more values ​​obtained at each of 2 or more visits after the initial check with the doctor. Unusually low readings should also be assessed from the point of view of clinical significance, because they can not only worsen the patient’s well-being, but also be a sign of serious pathology.

Classification of arterial hypertension: it can be primary, developed due to genetic reasons. However, the true cause of the disease remains unknown. Secondary hypertension is caused by various diseases of other organs. Essential (without apparent cause) arterial hypertension is observed in 95% of all cases in adults and is called hypertension. In children, secondary hypertension predominates, which is one of the signs of some other disease.

Severe arterial hypertension, which cannot be treated, is often associated with an unrecognized secondary form, for example, with primary hyperaldosteronism. The uncontrolled form is diagnosed when, with a combination of three different antihypertensive medications, including a diuretic, the blood pressure does not reach normal.

Clinical signs

Symptoms of arterial hypertension are often only objective, that is, the patient does not feel any complaints until he experiences target organ damage. This is the insidiousness of the disease, because at stages II–III, when the heart, kidneys, brain, and fundus of the eye are already affected, it is almost impossible to reverse these processes.

What signs should you pay attention to and consult a doctor, or at least start measuring your blood pressure yourself using a tonometer and recording it in your self-monitoring diary:

• dull pain in the left side of the chest;
• heart rhythm disturbances;
• pain in the back of the head;
• periodic dizziness and tinnitus;
• deterioration of vision, appearance of spots, “floaters” before the eyes;
• shortness of breath on exertion;
• cyanosis of hands and feet;
• swelling or swelling of the legs;
• attacks of suffocation or hemoptysis.

An important part of the fight against hypertension is a timely, comprehensive medical examination, which every person can undergo free of charge in their clinic. There are also Health Centers throughout the country, where doctors will talk about the disease and carry out its initial diagnosis.

Hypertensive crisis and its dangers

During a hypertensive crisis, the pressure increases to 190/110 mmHg. Art. and more. Such arterial hypertension can cause damage to internal organs and various complications:

• neurological: hypertensive encephalopathy, cerebral vascular accidents, cerebral infarction, subarachnoid hemorrhage, intracranial hemorrhage;
• cardiovascular: myocardial ischemia/infarction, acute pulmonary edema, aortic dissection, unstable angina;
• others: acute renal failure, retinopathy with vision loss, eclampsia in pregnancy, microangiopathic hemolytic anemia.

A hypertensive crisis requires immediate medical attention.

Gestational hypertension is part of the so-called OPG-preeclampsia. If you do not seek help from a doctor, you may develop preeclampsia and eclampsia - conditions that threaten the life of the mother and fetus.

Diagnosis

Diagnosis of arterial hypertension necessarily includes accurate measurement of the patient’s blood pressure, targeted history taking, general examination and obtaining laboratory and instrumental data, including a 12-channel electrocardiogram. These steps are necessary to determine the following provisions:

• damage to target organs (heart, brain, kidneys, eyes);
• probable causes of hypertension;
• baseline indicators for further assessment of the biochemical effects of therapy.

Based on a certain clinical picture or if secondary hypertension is suspected, other tests may be performed - the level of uric acid in the blood, microalbuminuria (protein in the urine).

• echocardiography to determine the condition of the heart;
• ultrasound examination of internal organs to exclude damage to the kidneys and adrenal glands;
• tetrapolar rheography to determine the type of hemodynamics (treatment may depend on this);
• blood pressure monitoring on an outpatient basis to clarify fluctuations during the day and night hours;
• 24-hour electrocardiogram monitoring combined with determination of sleep apnea.

If necessary, an examination by a neurologist, ophthalmologist, endocrinologist, nephrologist and other specialists is prescribed, and a differential diagnosis of secondary (symptomatic) hypertension is carried out.

Treatment of arterial hypertension as a first step involves lifestyle modification.

Lifestyle

Reducing blood pressure and heart risk is possible by following at least 2 of the following rules:

• weight loss (with a loss of 10 kg, pressure decreases by 5 - 20 mm Hg);
• reducing alcohol consumption to 30 mg of ethanol for men and 15 mg of ethanol for women of normal weight per day;
• salt intake no more than 6 grams per day;
• sufficient intake of potassium, calcium and magnesium from food;
• quitting smoking;
• reducing the intake of saturated fats (i.e. solid fats, animal fats) and cholesterol;
• aerobic exercise for half an hour a day almost every day.

Drug treatment

If hypertension persists despite all measures, there are various drug therapy options. In the absence of contraindications and only after consultation with a doctor, the first-line drug is usually a diuretic. It must be remembered that self-medication can cause irreversible negative consequences in patients with hypertension.

If there is a risk or an additional condition has already developed, other components are included in the treatment regimen: ACE inhibitors (enalapril and others), calcium antagonists, beta blockers, angiotensin receptor blockers, aldosterone antagonists in various combinations. The selection of therapy is carried out on an outpatient basis for a long time until the optimal combination for the patient is found. It will need to be used constantly.

Patient Information

Hypertension is a lifelong disease. It is impossible to get rid of it, with the exception of secondary hypertension. For optimal control over the disease, constant work on oneself and drug treatment are necessary. The patient should attend the “School for Patients with Arterial Hypertension,” because adherence to treatment reduces cardiovascular risk and increases life expectancy.

What a patient with hypertension should know and do:

• maintain normal weight and waist circumference;
• exercise regularly;
• eat less salt, fat and cholesterol;
• consume more minerals, in particular potassium, magnesium, calcium;
• limit the consumption of alcoholic beverages;
• stop smoking and using psychostimulants.

Regular blood pressure monitoring, doctor visits, and behavior modification will help a patient with hypertension maintain a high quality of life for many years.

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Features of stage 3 hypertension

1. What is stage 3 hypertension?
2. Risk groups of patients with hypertension
3. Symptoms
4. What to pay attention to
5. Reasons for the development of stage 3 hypertension

Hypertension is a fairly common problem. The most dangerous option is stage 3 of this disease, but when making a diagnosis, the stage and degree of risk are indicated.

People who have high blood pressure should understand the dangers of this in order to take adequate measures in time and not increase the already high risk of complications. For example, if the diagnosis is hypertension risk 3, what is it, what do these numbers mean?

They mean that a person with such a diagnosis has a 20 to 30% risk of developing a complication due to hypertension. If this indicator is exceeded, a diagnosis of stage 3 hypertension is made, risk 4. Both diagnoses mean the need for urgent treatment measures.

What is stage 3 hypertension?

This degree of the disease is considered severe. It is determined by blood pressure indicators, which look like this:

• Systolic pressure 180 or more mmHg;
• Diastolic – 110 mmHg. and higher.

In this case, the blood pressure level is always elevated and almost constantly remains at levels that are considered critical.

Risk groups of patients with hypertension

In total, it is customary to distinguish 4 such groups depending on the likelihood of damage to the heart, blood vessels and other target organs, as well as the presence of aggravating factors:

• 1 risk – less than 15%, no aggravating factors;
• 2 risk – from 15 to 20%, no more than three aggravating factors;
• 3 risk – 20-30%, more than three aggravating factors;
• 4 risk – above 30%, more than three aggravating factors, target organ damage.

Aggravating factors include smoking, insufficient physical activity, excess weight, chronic stress, poor nutrition, diabetes, and endocrine disorders.

With hypertension of 3 degrees with risk 3, a health threat arises. Many patients are in risk group 4. A high risk is also possible with lower blood pressure levels, since each organism is individual and has its own safety margin.

In addition to the degree and risk group, the stage of hypertension is also determined:

• 1 – no changes or damage in target organs;
• 2 – changes in several target organs;
• 3 – except for target organ damage plus complications: heart attack, stroke.

Symptoms

When hypertension develops to grade 3 with risks 3 and 4, it is impossible not to notice the symptoms, because they manifest themselves quite clearly. The main symptom is critical levels of blood pressure, which causes all other manifestations of the disease.

Possible manifestations:

• Dizziness and headaches with throbbing;
• Flashing “flies” before the eyes;
• General deterioration of condition;
• Weakness in the arms and legs;
• Vision problems.

Why do these symptoms occur? The main problem with hypertension is damage to vascular tissue. High blood pressure increases the load on the vascular wall.

In response to this, the inner layer is damaged, and the muscle layer of the vessels increases, which is why their lumen narrows. For the same reason, the vessels become less elastic, cholesterol plaques form on their walls, the lumen of the vessels narrows even more, and blood circulation becomes even more difficult.

In general, the health risk is very high, and grade 3 hypertension with a risk of grade 3 threatens disability quite realistically. Target organs are especially affected:

• Heart;
• Kidneys;
• Brain;
• Retina of the eye.

What happens in the heart

The left ventricle of the heart expands, the muscle layer in its walls grows, and the elastic properties of the myocardium deteriorate. Over time, the left ventricle is not able to fully cope with its functions, which threatens the development of heart failure if timely and adequate measures are not taken.

Kidney damage

The kidneys are an organ that is abundantly supplied with blood, so they often suffer from high blood pressure. Damage to the renal vessels impairs their blood supply.

The result is chronic renal failure, since destructive processes in the blood vessels lead to changes in tissues, for this reason the functions of the organ are disrupted. Kidney damage is possible with stage 2 hypertension, stage 3, risk 3.

With hypertension, the brain also suffers from blood supply disturbances. This is due to sclerosis and decreased tone of blood vessels, the brain itself, as well as the arteries running along the spine.

The situation is aggravated if the patient’s vessels are highly tortuous, which often happens in this area of ​​the body, since tortuosity contributes to the formation of blood clots. As a result, with hypertension, without timely and adequate assistance, the brain does not receive enough nutrition and oxygen.

The patient's memory deteriorates and attention decreases. Encephalopathy may develop, accompanied by a decrease in intelligence. These are very unpleasant consequences, as they can lead to loss of performance.

The formation of blood clots in the vessels supplying the brain increases the likelihood of an ischemic stroke, and the release of a blood clot can lead to a hemorrhagic stroke. The consequences of such conditions can be catastrophic for the body.

Effects on the organs of vision

In some patients with grade 3 hypertension with grade 3 risk, damage to the vessels of the retina occurs. This negatively affects visual acuity, it decreases, and “spots” may also appear before the eyes. Sometimes a person feels pressure on the eyeballs, in this state he constantly feels drowsy, and his performance decreases.

Another danger is hemorrhage.

One of the dangerous complications of grade 3 hypertension with risk 3 is hemorrhages in various organs. This happens for two reasons.

1. Firstly, the thickening walls of blood vessels lose their elasticity so much that they become brittle.
2. Secondly, hemorrhages are possible at the site of the aneurysm, because here the walls of the vessels become thinner from overflow and are easily torn.

Minor bleeding as a result of a ruptured vessel or aneurysm leads to the formation of hematomas; in the case of large ruptures, hematomas can be large-scale and damage internal organs. Severe bleeding is also possible, which requires immediate medical attention to stop.

There is an opinion that a person immediately feels increased blood pressure, but this does not always happen. Everyone has their own individual sensitivity threshold.

The most common variant of the development of hypertension is the absence of symptoms until the onset of a hypertensive crisis. This already means the presence of hypertension, stage 2, stage 3, since this condition indicates organ damage.

The period of asymptomatic disease can be quite long. If a hypertensive crisis does not occur, then the first symptoms gradually appear, to which the patient often does not pay attention, attributing everything to fatigue or stress. This period can even last until the development of arterial hypertension of degree 2 with a risk of 3.

What to pay attention to

• Regular dizziness and headaches;
• Feeling of tightness in the temples and heaviness in the head;
• Tinnitus;
• "Floaters" before the eyes;
• General decrease in tone4
• Sleep disorders.

If you do not pay attention to these symptoms, then the process goes further, and the increased load on the vessels gradually damages them, they cope with their work less and less, and the risks grow. The disease moves to the next stage and the next degree. Arterial hypertension grade 3, risk 3, can progress very quickly.

This results in more severe symptoms:

• Irritability;
• Memory loss;
• Shortness of breath with little physical exertion;
• Visual impairment;
• Interruptions in the functioning of the heart.

With grade 3 hypertension, risk 3, the likelihood of disability is high due to large-scale vascular damage.

Reasons for the development of stage 3 hypertension

The main reason why such a serious condition as stage 3 hypertension develops is the lack of treatment or insufficient therapy. This can happen both through the fault of the doctor and the patient himself.

If the doctor is inexperienced or inattentive and has developed an inappropriate treatment regimen, then it will not be possible to lower blood pressure and stop the destructive processes. The same problem awaits patients who are inattentive to themselves and do not follow the specialist’s instructions.

For correct diagnosis, anamnesis is very important, that is, information obtained during examination, familiarization with documents and from the patient himself. Complaints, blood pressure indicators, and the presence of complications are taken into account. Blood pressure should be measured regularly.

To make a diagnosis, the doctor needs data for dynamic monitoring. To do this, you need to measure this indicator twice a day for two weeks. Blood pressure measurement data allows you to assess the condition of blood vessels.

Other diagnostic measures

• Listening to lungs and heart sounds;
• Percussion of the vascular bundle;
• Determination of heart configuration;
• Electrocardiogram;
• Ultrasound of the heart, kidneys and other organs.

To clarify the state of the body, it is necessary to do tests:

• Blood plasma glucose levels;
• General blood and urine analysis;
• Level of creatinine, uric acid, potassium;
• Determination of creatinine clearance.

In addition, the doctor may prescribe additional examinations necessary for a particular patient. In patients with stage 3 hypertension, stage 3, risk 3, there are additional aggravating factors that require even more careful attention.

Treatment of stage 3 hypertension, risk 3, involves a set of measures that includes drug therapy, diet and an active lifestyle. It is mandatory to give up bad habits - smoking and drinking alcohol. These factors significantly aggravate the condition of blood vessels and increase risks.

For the treatment of hypertension with risks 3 and 4, drug treatment with one drug will not be enough. A combination of drugs from different groups is required.

To ensure stability of blood pressure, long-acting drugs are mainly prescribed, which last up to 24 hours. The selection of drugs for the treatment of stage 3 hypertension is carried out based not only on blood pressure indicators, but also on the presence of complications and other diseases. The prescribed drugs should not have side effects that are undesirable for a particular patient.

Main groups of drugs

• Diuretics;
• ACE inhibitors;
• β-blockers;
• Calcium channel blockers;
• AT2 receptor blockers.

In addition to drug therapy, it is necessary to adhere to a diet, work and rest, and give yourself feasible exercise. The results of treatment may not be noticeable immediately after it begins. It takes a long time for symptoms to begin to improve.

Adequate nutrition for hypertension is an important part of treatment.

You will have to exclude foods that contribute to a rise in blood pressure and the accumulation of cholesterol in the blood vessels.

Salt consumption should be kept to a minimum, ideally no more than half a teaspoon per day.

Prohibited Products

• Smoked meats;
• Pickles;
• Spicy dishes;
• Coffee;
• Semi-finished products;
• Strong tea.

It is impossible to completely cure arterial hypertension of the 3rd degree, risk 3, but it is possible to stop the destructive processes and help the body recover. The life expectancy of patients with stage 3 hypertension depends on the degree of development of the disease, the timeliness and quality of treatment, and the patient’s compliance with the recommendations of the attending physician.