Arterial hypertension (hypertension, essential hypertension) is one of the most common diseases of our time, and it leads to the development of cardiovascular diseases, with the appearance of which life becomes not a joy.
Arterial hypertension (AH) is a periodic or persistent increase in blood pressure (BP). According to the World Health Organization, a safe blood pressure level is less than 140/90 mm Hg.
Classification of blood pressure levels
Blood pressure (BP) is the force with which the blood flow puts pressure on the vessels and the organs they feed: the brain, heart, kidneys. With long-term hypertension, the above pathological processes (even in the absence of complaints) can lead to stroke, coronary heart disease (angina), myocardial infarction, heart and kidney failure. Sharp and unexpected jumps in blood pressure can cause severe headaches and dizziness that cannot be relieved with traditional medications.
It is impossible to completely cure this disease, but blood pressure can be kept under control. The earlier you identify arterial hypertension and begin to monitor it over time, the lower the risk of developing complications of hypertension in the future.
Without measuring blood pressure, it is impossible to identify the disease!
The causes of arterial hypertension remain unknown in 90% of cases. However, certain factors are known to increase the risk of developing arterial hypertension:
- Age (high blood pressure most often develops in people over 35 years of age, and the older a person is, the higher their blood pressure figures tend to be. With age, the walls of large arteries become more rigid, and because of this, vascular resistance to blood flow increases, therefore, blood pressure rises).
- Hereditary predisposition (hypertension in first-degree relatives (father, mother, grandparents, siblings) reliably means an increased likelihood of developing the disease. The risk increases even more if two or more relatives had high blood pressure).
- Smoking (components of tobacco smoke, entering the blood, cause vasospasm. Not only nicotine, but also other substances contained in tobacco contribute to mechanical damage to the walls of the arteries, which predisposes to the formation of atherosclerotic plaques in this place).
- Excessive alcohol consumption (daily consumption of strong alcoholic beverages increases blood pressure by 5–6 mmHg per year).
- Excessive exposure to stress (the stress hormone adrenaline causes the heart to beat, pumping a large volume of blood per unit of time, as a result of which blood pressure rises). If stress continues for a long time, then the constant load wears out the blood vessels and the increase in blood pressure becomes chronic.
- Atherosclerosis (excess cholesterol leads to loss of elasticity in the arteries, and atherosclerotic plaques narrow the lumen of blood vessels, which makes it difficult for the heart to function. All this leads to increased blood pressure). However, hypertension, in turn, spurs the development of atherosclerosis, so that these diseases are risk factors for each other.
- Excessive salt consumption (a person consumes much more table salt with food than his body needs. Excess salt in the body often leads to spasm of the arteries, fluid retention in the body and, as a result, to the development of hypertension).
- Obesity (overweight people have higher blood pressure than thin people). It is estimated that every kilogram of excess weight means an increase in blood pressure by 2 mmHg).
- Insufficient physical activity (people who lead a sedentary lifestyle are 20–50% more likely to develop hypertension than those who actively engage in sports or physical labor. An untrained heart copes worse with stress, and metabolism is slower).
PREVENTION OF ARTERIAL HYPERTENSION:
Prevention of arterial hypertension is divided into primary and secondary.
PRIMARY PREVENTION OF HYPERTENSION is the prevention of the occurrence of the disease. That is, this prevention should be followed by healthy people whose blood pressure does not yet exceed normal values. The following set of health measures will help not only keep your blood pressure normal for many years, but also get rid of excess weight and significantly improve your overall well-being.
Exercise stress
Any physical exercise in persons with mild and moderate hypertension helps to increase the physical performance of the body. Exercises aimed at training endurance (strengthening exercises, breathing exercises, exercise equipment, swimming, walking, running, cycling) lead to a noticeable antihypertensive effect. It is recommended to exercise 30 minutes a day, gradually increasing the intensity from light to moderate (3-5 times a week).
Low salt diet
The amount of table salt should be limited to 5 grams (1 teaspoon). It should be noted that many products (cheeses, smoked meats, pickles, sausages, canned food, mayonnaise, etc.) themselves contain a lot of salt. So, remove the salt shaker from the table and never add salt to ready-made dishes. Replace salt with herbs and garlic. If it is difficult to do without salt, you can purchase salt with a reduced sodium content, the taste of which is almost no different from regular salt.
Limiting animal fats
Gradually replace butter, cheeses, sausages, sour cream, lard and fried cutlets from your diet with additional vegetables and fruits, vegetable oil and lean fish. Prefer low-fat dairy products. Thus, you will be able to control the cholesterol level in the blood (prevention of atherosclerosis), normalize weight and at the same time enrich your diet with potassium, which is very useful for arterial hypertension. Sources of potassium include various fruits and vegetables. It is advisable to eat at least 5 servings of vegetable or fruit salads and desserts per day.
Psychological relief
Stress is one of the main causes of increased blood pressure. Therefore, it is very important to master methods of psychological relief - auto-training, self-hypnosis, meditation. It is important to strive to see the positive sides in everything, to find joy in life, to work on your character, changing it towards greater tolerance for other people’s shortcomings, optimism, and balance. Hiking, sports, hobbies and spending time with pets also help maintain mental balance.
Rejection of bad habits
Bad habits and hypertension are a terrible combination, which in most cases leads to tragic consequences. You should completely stop smoking and reduce your alcohol intake. For strong drinks (40°) it is 50 g/day.
SECONDARY PREVENTION OF HYPERTENSION - carried out if the patient is diagnosed with arterial hypertension. Its main goal is to avoid the dangerous complications of arterial hypertension (coronary heart disease, heart attack, cerebral stroke). Secondary prevention includes two components: non-drug treatment of arterial hypertension and antihypertensive (drug) therapy.
Non-drug treatment of hypertension
Corresponds to primary prevention, but is carried out in a more stringent form. If each individual person cannot change heredity and environment, then lifestyle and nutrition can. All restrictions become immutable rules of behavior.
Antihypertensive (drug) therapy
This therapy is associated with taking a certain set of drugs that specifically act on high blood pressure levels, reducing it. The course of taking such medications is prescribed for life, thereby preventing the risk of developing cardiovascular complications.
So, if you have been diagnosed with arterial hypertension, then you need to:
- be sure to take all medications prescribed by the doctor (follow the doctor’s recommendations and be sure to read the instructions);
- Never miss taking your medications because your blood pressure is normal. It is better to discuss your observations with your doctor;
- do not stop taking medications if blood pressure levels become normal. They have become normal precisely because you are taking medications.
BE HEALTHY!
DO NOT BE ILL!
Publications in the media
Arterial hypertension (AH, systemic hypertension) is a condition in which systolic blood pressure exceeds 140 mm Hg. and/or diastolic blood pressure exceeds 90 mmHg. (as a result of at least three measurements made at different times against the background of a calm environment; the patient should not take drugs that either increase or decrease blood pressure) • If the causes of hypertension can be identified, then it is considered secondary (symptomatic) • In the absence obvious cause of hypertension, it is called primary, essential, idiopathic, and in our country - hypertension • Isolated systolic hypertension is diagnosed when systolic blood pressure increases more than 140 mm Hg. and diastolic blood pressure less than 90 mm Hg • Hypertension is considered malignant when diastolic blood pressure is more than 120 mm Hg.
Statistics • 20–30% of the adult population suffers from hypertension. The prevalence increases with age and reaches 50–65% in people over 65 years of age, and in the elderly, isolated systolic hypertension is more common, which occurs in less than 5% of the population under the age of 50 years. Before the age of 50, hypertension is more common in men, and after 50 years - in women. Among all forms of hypertension, mild and moderate account for about 70–80%, in other cases severe hypertension is observed • Secondary hypertension accounts for 5–10% of all cases of hypertension, the remaining cases are essential hypertension (hypertension). However, according to specialized clinics, using complex and expensive research methods, secondary hypertension can be detected in 30–35% of patients.
Etiology and pathogenesis • The etiology of hypertension is currently far from completely clear; genetic abnormalities have been identified (see Genetic aspects below). Etiology of secondary hypertension - see Symptomatic arterial hypertension • The main factors determining the level of blood pressure are cardiac output and peripheral vascular resistance. An increase in cardiac output and/or peripheral vascular resistance leads to an increase in blood pressure and vice versa • In the development of hypertension, both internal humoral and neurogenic (renin-angiotensin system, sympathetic nervous system, baro- and chemoreceptors) and external factors (excessive consumption of table salt, alcohol, smoking, obesity) •• Prevalence of vasopressor factors - renin, angiotensin II, vasopressin, endothelin •• Vasodepressor factors - natriuretic peptides, kallikrein-kinin system, adrenomedullin, nitric oxide, Pg (PgI2, prostacyclin).
Genetic aspects. There are many known genetic abnormalities that contribute to the development of hypertension: mutations: angiotensin gene, aldosterone synthetase, b-subunit of amiloride-sensitive sodium channels of the renal epithelium, as well as a lot of loci of the so-called predisposition to the development of hypertension.
Risk factors • Complicated family history •• Lipid metabolism disorders in the patient and his parents •• Diabetes in the patient and his parents •• Kidney disease in parents (polycystic disease) • Obesity • Alcohol abuse • Excessive consumption of table salt • Stress • Physical inactivity • Smoking • Patient's personality type.
At-risk groups. Due to the involvement of various organs and systems in the pathological process, their influence on the course of the disease, groups of patients with high and very high risk are distinguished • The high-risk group includes patients with three or more risk factors, patients with target organ damage or patients with diabetes • The very high-risk group includes patients with concomitant diseases and risk factors.
Classification. Currently, two classifications are common in Russia - WHO and the International Society of Hypertension (1999) and WHO (1978).
Classification of hypertension by WHO and International Society of Hypertension (1999) • Optimal •• Systolic blood pressure: <120 mm Hg •• Diastolic blood pressure <80 mm Hg • Normal •• Systolic blood pressure <130 mm Hg •• Diastolic blood pressure < 85 mm Hg • High normal: •• Systolic blood pressure 130–139 mm Hg •• Diastolic blood pressure 85–89 mm Hg • Grade I (mild) •• Systolic blood pressure 140–159 mm Hg •• Diastolic blood pressure 90–99 mm Hg • subgroup: borderline •• Systolic blood pressure 140–149 mm Hg •• Diastolic blood pressure 90–94 mm Hg • Grade II (moderate) •• Systolic blood pressure 160–179 mm Hg .st •• Diastolic blood pressure 100–109 mm Hg • III degree (severe) •• Systolic blood pressure >180 mm Hg •• Diastolic blood pressure >110 mm Hg • Isolated systolic •• Systolic blood pressure >140 mm Hg .st •• Diastolic blood pressure <90 mm Hg • subgroup: borderline •• Systolic blood pressure 140–149 mm Hg •• Diastolic blood pressure <90 mm Hg • Note. When determining the degree, the highest blood pressure value should be used, for example 140/100 mmHg. — II degree of hypertension.
WHO classification of hypertension (1978) • Stage I - increased blood pressure more than 160/95 mm Hg. without organic changes in the cardiovascular system • stage II - high blood pressure •• with hypertrophy of the left ventricle of the heart •• either with proteinuria and/or a slight increase in the concentration of creatinine in the blood plasma (not more than 176.8 µmol/l) •• or with widespread or localized ( retina) changes in arteries • Stage III - high blood pressure with damage to the heart, brain, retina, kidneys (myocardial infarction, heart failure, cerebrovascular accident, retinal hemorrhage, renal failure).
Blood pressure measurement
• Measurement must be carried out after resting for 5 minutes. 30 minutes before this, it is not recommended to eat, drink coffee, drink alcohol, exercise, or smoke. When measuring, your legs should not be crossed, your feet should be on the floor, your back should rest on the back of the chair. A hand rest is required, and the bladder must be emptied before measurement. Failure to comply with these conditions can lead to an increase in blood pressure: after drinking coffee - by 11/5 mm Hg, alcohol - by 8/8 mm Hg, smoking - by 6/5 mm Hg, with a full urinary bladder - 15/10 mm Hg, in the absence of support for the back - systolic by 6–10 mm Hg, in the absence of support for the arm - by 7/11 mm Hg.
• The shoulder should be at the level of the IV–V intercostal space (a low elbow position increases systolic blood pressure by an average of 6 mm Hg, a high elbow position underestimates blood pressure by 5/5 mm Hg). The shoulder should not be compressed by clothing (measurement through clothing is unacceptable) - systolic pressure may be overestimated by 5–50 mmHg. The lower edge of the cuff should be 2 cm above the elbow (improper application of the cuff can lead to an overestimation of blood pressure by 4/3 mmHg), and it should fit snugly to the upper arm. The air in the cuff should be inflated to 30 mm Hg. above the disappearance of the pulse on the radial artery. The stethoscope should be placed in the cubital fossa. The moment the first sounds appear will correspond to phase I of Korotkoff sounds and shows systolic blood pressure. The rate of decrease in pressure in the cuff is 2 mm/s (slow decompression increases blood pressure by 2/6 mm Hg, fast decompression increases diastolic blood pressure). The moment of disappearance of the last sounds will correspond to the V phase of Korotkoff sounds and corresponds to diastolic blood pressure.
• Measured parameters should be indicated with an accuracy of 2 mmHg. When measuring, it is necessary to listen to the area of the cubital fossa until the pressure in the cuff decreases to zero (you should remember about possible aortic valve insufficiency and other pathological conditions with high pulse pressure, large stroke volume of the heart). During each examination of the patient, blood pressure is measured at least twice on the same arm and the average values are recorded. During the first examination, the pressure is measured on both arms, and subsequently on the arm where it was higher. The difference in blood pressure between the left and right arms should not exceed 5 mmHg. More significant differences should be alarming regarding vascular pathology of the upper extremities.
• When measuring blood pressure with the patient lying down, his arm should be slightly elevated (but not suspended) and be at the level of the middle of the chest.
• Repeated measurements should be carried out under the same conditions. It is necessary to measure blood pressure in a patient in two positions - lying and sitting - in the elderly, with diabetes, in patients taking peripheral vasodilators (to identify possible orthostatic arterial hypotension).
Clinical manifestations are nonspecific and depend on target organ damage.
• Cerebral symptoms •• The main symptom is headache, often on awakening and usually in the occipital region •• Dizziness, blurred vision, transient cerebrovascular accident or stroke, retinal hemorrhages or papilledema, movement disorders and sensory disorders • Intellectual-mnestic disorders.
• Cardiac symptoms •• Palpitations, pain in the heart area, shortness of breath (due to pronounced changes in the heart with hypertension, every second patient has cardiac symptoms) •• Clinical manifestations of coronary artery disease •• Left ventricular dysfunction or heart failure.
• Kidney damage: thirst, polyuria, oliguria, nocturia, microhematuria.
• Peripheral arterial disease: cold extremities, intermittent claudication.
• Hypertension is often asymptomatic.
• It is possible to detect (by palpation) volumetric formations in the kidney area, as well as listen to a systolic murmur over the kidney area.
• Examination - signs of some endocrine diseases accompanied by hypertension: hypothyroidism, thyrotoxicosis, Itsenko-Cushing syndrome, pheochromocytoma, acromegaly.
• Palpation of peripheral arteries, auscultation of vessels, heart, chest, abdomen suggest vascular damage as the cause of hypertension, suspect aortic disease, suggest renovascular hypertension.
Features of collecting anamnesis • Family history of hypertension, diabetes, lipid metabolism disorders, coronary heart disease, stroke, kidney disease • Duration of hypertension and its evolution, previous blood pressure level, results and side effects of previous antihypertensive treatment • Presence and course of coronary artery disease, heart failure, stroke, other diseases in this patient (gout, bronchospastic conditions, dyslipidemia, sexual dysfunction, kidney disease) • Clarification of symptoms of presumably secondary hypertension • Detailed questioning about taking medications that increase blood pressure (GCs, oral contraceptives, NSAIDs, amphetamines, epoetin beta, cyclosporine) • Lifestyle assessment (consumption of table salt, fat, alcohol, smoking, physical activity) • Personal, psychosocial and external factors influencing blood pressure (family, work).
Laboratory and special research methods. It is necessary to exclude symptomatic hypertension, identify risk factors and the degree of target organ involvement.
• OAC (anemia, erythrocytosis, leukocytosis, increased ESR - secondary hypertension).
• OAM - leukocyturia, erythrocyturia, proteinuria, cylindruria (symptomatic hypertension), glucosuria (DM).
• Biochemical tests to determine the concentration of potassium ions, creatinine, glucose, cholesterol (secondary hypertension, risk factors). It should be remembered that a rapid decrease in blood pressure with long-term hypertension of any etiology can lead to an increase in creatinine levels in the blood.
• ECG - left ventricular hypertrophy, rhythm and conduction disturbances, electrolyte disturbances, signs of ischemic heart disease (changes in the terminal part of the ventricular complex, scar changes).
• EchoCG to detect left ventricular hypertrophy, assess myocardial contractility, and identify valvular defects as a cause of hypertension.
• Ultrasound of the kidneys, adrenal glands, renal arteries, peripheral vessels to identify secondary hypertension.
• Fundus examination: hypertensive retinopathy - narrowing and sclerosis of the arteries (symptoms of copper or silver wire), Salus phenomenon.
Diagnostic tactics. The diagnosis of hypertension (essential, primary hypertension) is established only by excluding secondary hypertension. Goals of diagnostic measures for hypertension • Determination of a possible cause • Identification of concomitant diseases • Identification of risk factors for coronary artery disease. Since hypertension itself is one of the risk factors for CHD, the presence of another risk factor further increases the likelihood of developing CHD; in addition, the prescribed treatment can seriously affect risk factors - for example, diuretics and non-selective beta-blockers in the presence of dyslipidemia and insulin resistance can aggravate these disorders • Identification of target organ involvement in the hypertensive process. Their defeat has the most serious impact on the prognosis of the disease and approaches to its treatment.
Differential diagnosis • Renoparenchymal hypertension - see Arterial hypertension, renoparenchymal • Vasorenal hypertension - see Arterial vasorenal hypertension • Endocrine hypertension constitutes approximately 0.1–1% of all hypertension (up to 12% according to specialized clinics) •• With pheochromocytoma (see Pheochromocytoma ) •• With primary hyperaldosteronism (see Hyperaldosteronism) •• With hypothyroidism - high diastolic blood pressure; other manifestations of the cardiovascular system - decreased heart rate and cardiac output •• In hyperthyroidism - increased heart rate and cardiac output, predominantly isolated systolic hypertension with low (normal) diastolic blood pressure; an increase in diastolic blood pressure in hyperthyroidism is a sign of another disease accompanied by hypertension or a sign of hypertension • Drug hypertension - vasoconstriction due to sympathetic stimulation or direct effects on vascular SMCs, increased blood viscosity, stimulation of the renin-angiotensin system, ion retention may be important in the pathogenesis sodium and water, interaction with central regulatory mechanisms - for more details, see Symptomatic Arterial Hypertension.
TREATMENT
The goal is to reduce cardiovascular morbidity and mortality by normalizing blood pressure, protecting target organs, eliminating risk factors (smoking cessation, compensation for diabetes, reducing the concentration of cholesterol in the blood and excess body weight).
• Recommendations of WHO and IAH (International Society of Arterial Hypertension; 1999) •• In young and middle-aged people, as well as in patients with diabetes, it is necessary to maintain blood pressure at the level of 130/85 mm Hg •• In elderly people, the target blood pressure level is £140 /90 mmHg
• Excessive rapid decrease in blood pressure with significant duration and severity of the disease can lead to hypoperfusion of vital organs - the brain (hypoxia, stroke), heart (exacerbation of angina, myocardial infarction), kidneys (renal failure).
Treatment plan • Control of blood pressure and risk factors • Lifestyle changes • Drug therapy.
Non-drug treatment is indicated for all patients. In 40–60% of patients with the initial stage of hypertension with low blood pressure values, it is normalized without the use of drugs. In case of severe hypertension, non-drug therapy in combination with medication helps to reduce the dose of drugs taken and thereby reduces the risk of their side effects. The mechanisms leading to a decrease in blood pressure are considered to be a decrease in cardiac output, a decrease in peripheral vascular resistance, or a combination of both mechanisms.
• Diet •• Limiting table salt intake to less than 6 g/day (but not less than 1–2 g/day, since in this case compensatory activation of the renin-angiotensin system may occur) •• Limiting carbohydrates and fats, which is very important in the prevention of coronary heart disease , the likelihood of which is increased in hypertension (risk factor). A decrease in excess body weight by 1 kg leads to a decrease in blood pressure by an average of 2 mm Hg •• An increase in the content of potassium and calcium ions in the diet •• Refusal or significant limitation of alcohol intake (especially if it is abused).
• Physical activity - sufficient cyclic activity (walking, light jogging, skiing) in the absence of contraindications from the heart (coronary artery disease), blood vessels of the legs (atherosclerosis obliterans), central nervous system (cerebrovascular accidents) reduces blood pressure, and at low levels it can normalize his. Moderation and gradual dosing of physical activity is recommended. Physical activity with a high level of emotional stress (competition, gymnastics), as well as isometric efforts (weight lifting) are undesirable.
• Other methods - psychological (psychotherapy, autogenic training, relaxation), acupuncture, massage, physiotherapeutic methods (electrosleep, diadynamic currents, hyperbaric oxygenation), water procedures (swimming, shower, including contrast), herbal medicine (chokeberry, tincture of hawthorn, motherwort, mixtures with marsh cudweed, hawthorn, immortelle, sweet clover).
Drug therapy
Basic principles: • It is necessary to begin treatment of mild hypertension with small doses of drugs • Combinations of drugs should be used to increase their effectiveness and reduce side effects • It is preferable to use long-acting drugs (12–24 hours with a single dose).
• b-blockers •• Preference should be given to b-blockers when hypertension is combined with coronary artery disease (angina pectoris and unstable angina, post-infarction cardiosclerosis, heart failure), tachyarrhythmias, extrasystoles •• After abrupt withdrawal of b-blockers, withdrawal syndrome may develop, manifested by tachycardia, arrhythmias, increased blood pressure, exacerbation of angina, development of myocardial infarction, and in some cases even sudden cardiac death. To prevent withdrawal syndrome, a gradual reduction in the dose of the b-blocker is recommended for at least 2 weeks. There is a high-risk group for the development of withdrawal syndrome - these are people with hypertension in combination with angina pectoris, as well as with ventricular arrhythmias •• Drugs ••• Non-selective (blockade of b1- and b2-adrenergic receptors): propranolol 40–240 mg/day at 3 doses, pindolol 5–15 mg 2 times/day, timolol 10–40 mg/day in 2 divided doses ••• Selective (cardioselective) b1-blockers: atenolol 25–100 mg 2 times/day, metoprolol 50–200 mg/day in 2 doses, nadolol 40–240 mg/day, betaxolol 10–20 mg/day.
• Diuretics •• Varieties ••• Thiazides and thiazide-like diuretics (used most often in the treatment of hypertension) are diuretics of moderate potency, suppress the reabsorption of 5–10% of sodium ions (drugs: hydrochlorothiazide 12.5–50 mg/day, cyclopenthiazide 0, 5 mg/day, chlorthalidone 12.5–50 mg/day) ••• Loop diuretics (characterized by the rapid onset of action when administered parenterally) are strong diuretics, suppress the reabsorption of 15–25% of sodium ions (the main drug is indapamide 2.5 mg /day in one dose; furosemide at a dose of 20–320 mg/day is rarely prescribed for continuous use for antihypertensive purposes) ••• Potassium-sparing diuretics are weak diuretics, cause additional excretion of no more than 5% of sodium ions (drugs: spironolactone 25–100 mg / day, triamterene 50–100 mg 4 times / day.) •• Preference for diuretics in the treatment of hypertension is given if there is a tendency to edema and in old age.
• ACE inhibitors •• Preferred for the treatment of hypertension with the following concomitant conditions (diseases): ••• left ventricular hypertrophy (ACE inhibitors are most effective in its regression) ••• hyperglycemia ••• hyperuricemia ••• hyperlipidemia (ACE inhibitors do not aggravate these conditions) ••• history of myocardial infarction ••• heart failure (ACE inhibitors are among the most effective drugs for the treatment of heart failure; they not only weaken its clinical manifestations, but also increase the life expectancy of patients) ••• older age •• Drugs ••• captopril 25–150 mg/day ••• enalapril 2.5–40 mg/day ••• fosinopril 10–60 mg/day ••• lisinopril 2.5–40 mg/day ••• ramipril 2, 5–10 mg/day ••• benazepril 10–20 mg/day.
• Slow calcium channel blockers •• Preferred in the treatment of hypertension in combination with angina (especially vasospastic), dyslipidemia, hyperglycemia, broncho-obstructive diseases, hyperuricemia, supraventricular arrhythmias (verapamil, diltiazem), left ventricular diastolic dysfunction, Raynaud's syndrome •• With bradycardia or predisposition to it, a decrease in myocardial contractility, conduction disturbances, verapamil or diltiazem, which have pronounced negative inotropic, chronotropic and dromotropic effects, should not be prescribed, and, conversely, the use of dihydropyridine derivatives is indicated •• Due to the different sensitivity of patients to slow calcium channel blockers, treatment begins with small doses •• Drugs ••• Diltiazem 120–360 mg/day ••• Isradipine 2.5–15 mg/day ••• Nifedipine (extended dosage form) 30–120 mg/day ••• Nitrendipine 5–40 mg /day ••• Verapamil 120–480 mg/day ••• Amlodipine 2.5–10 mg/day ••• Felodipine 2.5–10 mg/day.
• Angiotensin II receptor blockers •• These drugs are preferable when a dry cough appears during treatment with ACE inhibitors, renal failure (especially in diabetes mellitus) •• Drugs ••• losartan 25–100 mg in 1 or 2 doses ••• valsartan 80 mg 1 time / day ••• eprosartan 600 mg 1 time / day ••• candesartan.
• a-blockers •• For long-term treatment of hypertension, selective a1-blockers are mainly used (prazosin 1–20 mg/day, doxazosin 1–16 mg/day, terazosin) •• This group of drugs is widely used in urology in the treatment of benign hyperplasia prostate gland •• Despite many positive effects, drugs in this group are rarely used as monotherapy. Apparently, this is due to disadvantages and side effects, although the danger of most of them is most likely exaggerated. The main indications are combination therapy •• Disadvantages: “first dose phenomenon” (pronounced decrease in blood pressure after the first dose), orthostatic arterial hypotension, long-term selection of the drug dose, development of tolerance (effect evasion), withdrawal syndrome. To prevent the “first dose phenomenon”, it is recommended to take an a-blocker in bed, followed by staying in a lying position for several hours (it is better to take it at night).
• Centrally acting drugs (in recent years they have gradually lost their importance) •• Centrally acting drugs cause a decrease in blood pressure due to inhibition of the deposition of catecholamines in central and peripheral neurons (reserpine), stimulation of central a2-adrenergic receptors (clonidine, guanfacine, methyldopa, moxonidine) and I1 -imidazoline receptors (clonidine and especially the specific agonist moxonidine), which ultimately weakens the sympathetic influence and leads to a decrease in peripheral vascular resistance, a decrease in heart rate and cardiac output •• Drugs in this group are mainly used orally for the treatment of hypertension. Preference should be given to imidazoline receptor agonists as first-line agents for diabetes and hyperlipidemia (they do not aggravate metabolic disorders), COPD (the drugs do not affect bronchial patency), severe hypersympathicotonia, left ventricular hypertrophy (they cause its regression). Methyldopa is most often used in the treatment of hypertension in pregnant women •• Drugs: reserpine and combination drugs containing it (reserpine + dihydralazine + hydrochlorothiazide, reserpine + dihydroergocristine + clopamide), methyldopa up to 2 g / day (when combined with other antihypertensive drugs, no more than 500 mg /day), clonidine at an initial dose of 0.075 3 times / day in 2 divided doses, moxonidine up to 0.4 mg / day in 2 divided doses, guanfacine 1-3 mg / day.
Combination therapy. According to international multicenter studies, the need for combination therapy occurs in 54–70% of patients. Indications for combination therapy are as follows: • Ineffectiveness of monotherapy. Monotherapy with an antihypertensive drug is effective on average in 50% of patients with hypertension (a higher result can be achieved, but then the risk of side effects will increase). To treat the remaining part of the patients, it is necessary to use a combination of two or more antihypertensive drugs • The need for additional protection of target organs, primarily the heart and brain.
Rational combinations of drugs. The most common combination of a diuretic and some other class of drug is used. In some countries, combination therapy with a diuretic is considered a mandatory step in the treatment of hypertension • The most effective combination is a combination of a diuretic and an ACE inhibitor (possibly a fixed combination, for example, capozide, Korenitek) • The combination of a diuretic and an angiotensin II receptor blocker is rational • Approximately the same additive effect has a combination of a diuretic and a beta-blocker (this combination is not the most successful, since both the diuretic and the beta-blocker affect the metabolism of glucose and lipids).
Irrational combinations of antihypertensive drugs can lead to both increased side effects and an increase in the cost of treatment if there is no effect. A striking example of an irrational combination is the combination of beta-blockers and slow calcium channel blockers (verapamil, diltiazem), since both groups of drugs worsen both myocardial contractility and AV conduction (increased side effects), while the combination of beta-blockers with dihydropyridines (for example, nifedipine) is positive.
Treatment of certain types of hypertension
• Resistant (refractory) hypertension - the inability to achieve a reduction in blood pressure to target values (less than 140/90 mm Hg) for more than 1 month in patients with hypertension during combination therapy with two or three antihypertensive drugs in sufficient dosages •• To confirm the diagnosis, it is necessary to test all rational combinations of drugs (primarily including diuretics, the combination “ACE inhibitor + slow calcium channel blocker” is also effective), then prescribe a triple combination in a variety of options, then a combination of four drugs (usually minoxidil is used as one of the components) • • One should remember about possible pseudo-resistance, the cause of which may be symptomatic hypertension, non-compliance with the rules of taking medications, inappropriate dosage, irrational combination of drugs, taking alcohol and drugs that increase blood pressure, weight gain, increased blood volume (for example, in heart failure), deliberate administration the patient misleads the doctor (simulation) •• In each case of resistant hypertension, a thorough examination of the patient is necessary, preferably in a specialized hospital to exclude symptomatic hypertension.
• Hypertension in the elderly •• Treatment should begin with non-drug measures, which in this case quite often reduce blood pressure to the target level. Of great importance is limiting the consumption of table salt and increasing the content of potassium and magnesium salts in the diet •• Drug treatment is based on the pathogenetic features of hypertension at a given age. In addition, it should be remembered that various concomitant diseases often occur in the elderly ••• It is necessary to start treatment with smaller doses (often half the standard) ••• The dose should be increased gradually over several weeks ••• The dose is selected under constant monitoring of blood pressure, and it is better to measure it in a standing position to identify possible orthostatic arterial hypotension ••• It is advisable to use a simple treatment regimen (1 tablet - 1 time / day) ••• You should use medications with caution that can cause orthostatic arterial hypotension (methyldopa, prazosin, labetalol) , and centrally acting drugs (clonidine, methyldopa, reserpine), the use of which in old age is quite often complicated by depression or pseudodementia. When treating with diuretics and/or ACE inhibitors, it is advisable to monitor renal function and blood electrolyte composition.
• Endocrine hypertension - see Symptomatic arterial hypertension.
• “Alcoholic” hypertension - see Symptomatic arterial hypertension.
Complications of hypertension: • MI • acute cerebrovascular accident • heart failure • renal failure • hypertensive encephalopathy • hypertensive retinopathy • hypertensive crisis • dissecting aortic aneurysm.
The prognosis significantly depends on the adequacy of the prescribed therapy and the patient’s compliance with medical recommendations.
Reduction. AH - arterial hypertension.
ICD-10 • I10 Essential (primary) hypertension • I11 Hypertensive heart disease [hypertensive disease with predominant damage to the heart] • I12 Hypertensive [hypertensive] disease with predominant damage to the kidneys • I13 Hypertensive [hypertensive] disease with predominant damage to the heart and kidneys • I15 Secondary hypertension • O10 Pre-existing hypertension complicating pregnancy, childbirth and the puerperium • O11 Pre-existing hypertension with associated proteinuria
Combination therapy for arterial hypertension
In Russia, 40% of men and women over 18 years of age have elevated blood pressure levels
(BP) [5].
The most important condition for effective antihypertensive therapy is adequate blood pressure control, i.e., achieving its target level, which is taken to be blood pressure <140/90 mm Hg. in all patients with hypertension. If the prescribed therapy is well tolerated, reducing blood pressure to lower values is considered useful. When hypertension is combined with diabetes mellitus or kidney damage, it is recommended to reduce blood pressure to a level of less than 130/80 mm Hg. [6]. However, in Russia, only 5.7% of men and 17.5% of women with hypertension achieve target blood pressure levels. Only 59% of women and 37% of men are aware of the existence of hypertension, only 46% of women and 21% of men are treated, but target blood pressure values are achieved only in 17.5% of women and 5.7% of men [7,8]. Thus, modern antihypertensive therapy should act on various systems through which blood pressure is regulated in the human body: the sympathetic-adrenal system, the renin-angiotensin-aldosterone system (RAAS), calcium metabolism, sodium-volume [9]. Influencing any of them allows you to achieve a decrease in blood pressure. According to the results of the meta-analysis BPLTTC-2003
(Blood Pressure Lowering Treatment Trialist Collaboration), four classes of antihypertensive drugs acting on different systems - angiotensin-converting enzyme inhibitors (ACE inhibitors), diuretics, β-blockers, calcium channel blockers showed equal effectiveness in preventing the development of cardiovascular events.
Currently, it is possible to use two strategies for treating hypertension to achieve target blood pressure: monotherapy and combination treatment. However, the results of many prospective clinical trials of antihypertensive therapy convincingly show that in the vast majority of cases it is impossible to achieve target blood pressure values with monotherapy. Each of these approaches has its own advantages and disadvantages. The advantage of monotherapy is that if the drug is successfully selected, the patient will not need to additionally take another drug. However, as a rule, with monotherapy it is possible to achieve target blood pressure on average only in 30–40% of patients with hypertension. This is quite natural, since one class of drugs is not able to control all pathogenetic mechanisms of increased blood pressure: the activity of the sympathetic nervous system and the renin-angiotensin-aldosterone system, volume-dependent mechanisms. Specifically, in the HOT
At study entry, 59% of patients were receiving monotherapy, whereas after 3.2 years only 32% of patients were taking a single antihypertensive drug. At the same time, there was a clear relationship between the target DBP and the frequency of combination therapy. To achieve DBP<90 mm Hg. combination therapy was required in 63% of cases, DBP<85 mmHg. – in 68%, and for DBP<80 mm Hg. – in 74% (and the average DBP in this group was 81 mm Hg, i.e., the goal was not achieved) [10]. The frequency of prescription of two or more antihypertensive drugs in other studies was also high: in the SHEP study - 45.0%, MAPHY - 48.5%, ALLHAT - 62.0%, STOP-Hypertension - 66.0%, IPPPSH - 70, 0%, INVEST – 84.0%, LIFE – 92.0%, COOPE – 93.0%, and in the VA study the combination was required in all patients.
The disadvantage of combination therapy is the inconvenience associated with the fact that the patient has to additionally take one more, and sometimes several, drugs. However, in most cases, the prescription of antihypertensive drugs with different mechanisms of action allows, on the one hand, to achieve target blood pressure, and on the other hand, to minimize the number of side effects. Combination therapy also makes it possible to suppress counterregulatory mechanisms of increased blood pressure. The use of a combination of antihypertensive drugs becomes undeniable, especially in the treatment of high-risk hypertension, in patients with kidney damage, in patients with diabetes mellitus, for whom target blood pressure values are lower. Initiation of treatment with a combination of drugs is most preferable in patients with lower target blood pressure values, with high and very high risk hypertension, as well as with a pronounced increase in blood pressure (160/100 mm Hg and above). In the latter case, the need to prescribe a combination of drugs is in most cases supported by American recommendations (Report of the Joint Committee, 2003).
There are various combinations of antihypertensive drugs. Among the combinations of two drugs, the following are considered effective and safe:
diuretic + β-blocker;
diuretic + ACE inhibitor; diuretic + angiotensin II receptor antagonist (ARA); dihydropyridine calcium antagonist + β-blocker; calcium antagonist + ACE inhibitor; calcium antagonist + diuretic; α-adrenergic blocker + β-adrenergic blocker; centrally acting drug + diuretic. In addition, combinations of an ACE inhibitor, calcium antagonist, ARB and diuretic with an I1 imidazoline receptor agonist are possible. The most popular in Russia is the combination of an ACE inhibitor and a diuretic. As the results of the PYTHAGORUS
, almost a third of doctors in Russia prefer a combination of these drugs [11]. The advantages of combination therapy include: enhanced antihypertensive effect due to mutual potentiation of the effect of individual drugs. This occurs due to the suppression of various pressor systems, as well as the neutralization of counter-regulatory mechanisms that reduce the effectiveness of individual drugs. Reducing the frequency of adverse events: firstly, mutual potentiation of the antihypertensive effect allows the use of lower doses of drugs in combinations, which reduces the frequency of side effects; secondly, most rational combinations ensure mutual neutralization of the side effects of individual drugs. Increased response rate to treatment and rate of achievement of target blood pressure levels. A combination of drugs that blocks multiple mechanisms for maintaining elevated blood pressure increases the likelihood of affecting the pressor system that is most active in a given patient. Prescribing combination therapy doubles the likelihood of response to treatment. This ensures more effective protection of the target organs of hypertension and, consequently, a more pronounced reduction in the risk of complications.
The combination of an ACE inhibitor and a diuretic is one of the most reasonable and convenient
.
Today it has been proven that ACE inhibitors and diuretics act synergistically and the effect of this combination is higher than that of each of these drugs separately. Diuretics, by reducing the volume of circulating blood, lead to compensatory activation of the renin-angiotensin-aldosterone system (RAAS), which limits their effectiveness. The addition of ACE inhibitors overcomes the activation of the RAAS and thereby enhances the effect of the diuretic. On the other hand, it is known that ACE inhibitors are less effective in the low-renin form of hypertension. Adding a diuretic in this situation increases the activity of the RAAS and increases the effectiveness of ACE inhibitors. The combined use of an ACE inhibitor and a diuretic makes it possible to mutually neutralize the side effects of both drugs. Diuretics lead to increased potassium excretion, while ACE inhibitors promote potassium retention; Accordingly, the combination provides prevention of both diuretic-induced hypokalemia and ACE inhibitor-induced hyperkalemia. Prevention of hypokalemia can be significant not only in terms of increasing tolerability of therapy. SHEP
study, patients with hypokalemia did not show a reduction in the incidence of adverse cardiovascular events compared with patients with normokalemia, despite the same reduction in blood pressure [12]. It is known that thiazide diuretics, in addition to hypokalemia, cause hyperuricemia, while ACE inhibitors help reduce it, because increase blood flow in the renal cortical layer, which leads to increased excretion of uric acid. A significant disadvantage of thiazide diuretics is their adverse effect on lipid and glucose metabolism. Combining diuretics with ACE inhibitors can reduce these undesirable effects, but often prevents them from being completely overcome.
Thus, in the Russian study EPIGRAPH
[13] assessed the effectiveness of a non-fixed combination of the ACE inhibitor enalapril and the thiazide diuretic indapamide.
The study involved 30 centers, which included 550 patients suffering from hypertension or secondary hypertension of renal origin with blood pressure levels above 160 and 90 mm Hg. The average age of those examined was 55.3±0.4 years; among those observed there were 319 (58%) women and 231 (42%) men. Initial blood pressure values averaged 174.1 and 100.6 mm Hg, arterial hypertension II. was observed in 452 (82%), stage III hypertension. – in 98 (18%) patients. Symptomatic renal hypertension (against the background of pyelonephritis or glomerulonephritis) was recorded in 198 (36.8%) patients. All patients were prescribed indapamide at a dose of 2.5 mg/day. Then all patients were divided into three groups depending on their SBP. In group 1 (124 patients) SBP was 160–170 mm Hg, in group 2 (328 patients) – 170–180 mm Hg, in group 3 (98 patients) >180 mm Hg .st. Patients in group 1 were prescribed enalapril at a dose of 5 mg/day, patients in group 2 – 10, and patients in group 3 – 20 mg/day. If target blood pressure levels were not achieved, enalapril doses were increased, which was required in 121 (22%) patients. As a result, the average daily dosage of enalapril at the end of the study was 15.2 mg in combination with indapamide at a dose of 2.5 mg. During the study, in the group as a whole, SBP decreased from 174.1±19.6 to 137.3 mmHg; the decrease was 38.8 mmHg, which corresponds to 20.4% of the initial value (p< 0.001). DBP also significantly decreased from 100.6±11.6 to 83.1±7.4 mmHg, the reduction amount was 17.5 mmHg, which corresponds to 14.7% of the initial level (p<0.001 ). The target blood pressure level was achieved in 385 out of 550 patients, i.e. in 70% of cases. The total indicator of blood pressure control, which included achieving target values in total with a decrease in blood pressure by 20/10 mm Hg. without achieving the target level was 77.1% (424 out of 550 patients). At the same time, a well-known pattern was noted: a decrease in DBP below 90 mm Hg. Art. was achieved in 521 (94.7%) patients, while SBP was below 140 mmHg. – only in 372 (67.7%). Combination therapy with enalapril and indapamide was well tolerated: side effects were detected in 45 (8.1%) patients, with symptoms associated with an excessive decrease in blood pressure predominant (5.4%), and only 15 (2.7%) patients had dry cough caused by taking enalapril. Thus, the combination of enalapril with indapamide was highly effective and the treatment was well tolerated
. It has been established that the effectiveness of combination therapy with enalapril and indapamide does not significantly depend on gender and age, as well as on the type of hypertension (essential or symptomatic). The proposed dosages of enalapril and indapamide generally provided a sufficient degree of effectiveness for hypertension of varying severity.
Based on the research, the drug Enzix
– an unfixed combination of enalapril and indapamide.
There are three types of Enzix: Enzix – 10 mg of enalapril and 2.5 mg of indapamide (single dose in the morning) for patients with stage I hypertension; Enisix Duo
– 10 mg enalapril and 2.5 mg indapamide (morning) + 10 mg enalapril (evening) for patients with stage II hypertension;
Enzix Duo Forte
– 20 mg enalapril and 2.5 mg indapamide (morning) + 20 mg enalapril (evening).
The effectiveness and safety of Enzix were assessed in the EPIGRAPH-2
, which was a comparative randomized multicenter study that included nine centers in Russia and one in Serbia [14]. A total of 313 patients were included in the study and randomized into two groups. The Enzix group included 211 patients, and the control group included 102 patients. The control group was treated with other classes of antihypertensive drugs (except ACE inhibitors and diuretics). The total duration of treatment was 14 weeks. All patients randomized to the Enzix group were divided into two subgroups depending on the initial blood pressure level. In the first subgroup, 118 patients with stage I hypertension and initial systolic blood pressure of 140–160 mm Hg. a combination of 10 mg enalapril and 2.5 mg indapamide (Enzix) was prescribed. During treatment, 88 (74.6%) of them continued to take the original dose, and in 26 (22.1%) patients the dose of enalapril was doubled (10 mg in the morning + 10 mg in the evening) while maintaining the dose of indapamide (2.5 mg in the morning ), which corresponded to Enzix Duo. Only one patient with stage I hypertension required a combination of 40 mg of enalapril (20 mg in the morning + 20 mg in the evening) and 2.5 mg of indapamide, which corresponded to Enzix Duo Forte. Three patients did not complete the study. In the second subgroup, 93 patients with stage II hypertension and systolic blood pressure of 160–180 mm Hg. therapy began with 20 mg enalapril (10 mg morning and evening) and 2.5 mg indapamide (Enzix Duo). During treatment, in 46 patients this dosage was maintained, and in 45 patients the dose of enalapril was increased to 40 mg/day. (20 mg in the morning + 20 mg in the evening) with a constant dose of indapamide 2.5 mg, which corresponded to Enzix Duo Forte. For two more patients, the initial dose of enalapril was reduced to 10 mg while maintaining the original dose of 2.5 mg of indapamide, which corresponded to Enzix.
When analyzing the number of patients whose blood pressure levels normalized as a result of treatment, the group of patients receiving Enzix (72.5%) had some advantages compared to the control group (66.7%). And this despite the fact that systolic blood pressure in the “experimental” group was initially 2.7 mm Hg. higher than in the control. If we sum up the total number of patients who responded positively to treatment (the number of patients with normalization of blood pressure or a decrease in systolic blood pressure by more than 20 mm Hg from the initial level), then by the end of treatment it reached 82.4% on average for the group, taking Enzix, and among patients with stage I hypertension this value was 89.8%, and in patients with stage II hypertension – 77.2%. Thus, early treatment of patients with grades I–II hypertension with a non-fixed combination of enalapril and indapamide (Enzix) in comparison with routine antihypertensive therapy makes it possible to achieve normalization of blood pressure levels more often. In addition, the Enzix group was able to significantly reduce the number of patients with left ventricular hypertrophy and proteinuria, improve quality of life, and reduce the number of hospitalizations and additional visits to the doctor.
It is known that fixed combinations, along with such advantages as ease of administration and increased adherence to treatment, also have disadvantages. In particular, the doctor cannot vary the doses of drugs included in a fixed combination, which does not allow individualization of treatment. If adverse reactions associated with one of the active principles occur, the combination as a whole must be discontinued. The presence of several dosage forms with different dosages allows these disadvantages to be overcome only partially. As a result, Enzix drugs were created, which are produced by Hemofarm AD and contain indapamide and enalapril tablets in one blister. The combination of drugs in one blister has a number of advantages: the possibility of titrating the dose of enalapril in various clinical situations, the ease of discontinuing the drug or reducing the dose if adverse events develop, the possibility of increasing the dose to enhance the antihypertensive effect by replacing the same form of the drug with a higher dosage of enalapril, which does not entail resulting in decreased adherence to treatment. The economic aspect of treatment also remains undoubtedly important. Thus, the drug Enzix with a non-fixed combination of enalapril and indapamide has established itself as a highly effective and safe drug for the treatment of arterial hypertension in various groups of patients.
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