National guidelines for the diagnosis and treatment of arterial hypertension

All-Russian Scientific Society of Cardiology (VNOK), section of arterial hypertension

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Introduction
In the Russian Federation, hypertension remains one of the most pressing medical problems. This is due to the fact that arterial hypertension (AH), which largely determines high cardiovascular morbidity and mortality, is characterized by widespread prevalence and, at the same time, lack of adequate control on a population scale. Even in countries with a high level of healthcare, this figure today does not exceed 25–30%, while in Russia blood pressure (BP) is properly controlled in only 8% of patients.
Large-scale population-based studies conducted around the world have clearly demonstrated the importance of effective treatment of hypertension in reducing the risk of cardiovascular morbidity and mortality, and also made it possible to quantify the impact on the prognosis of the relationship between blood pressure and other risk factors. Based on these data, new classifications of arterial hypertension were developed, necessary and sufficient target levels of blood pressure reduction during antihypertensive therapy were determined, and risk levels for developing cardiovascular complications in patients with hypertension were stratified. As a result of multicenter prospective clinical studies, the principles of non-drug and drug therapy, optimal treatment regimens, including in special patient populations, were formulated. On this basis, experts from the World Health Organization (WHO) and the International Society of Arterial Hypertension (ISH) prepared guidelines for the diagnosis, prevention and treatment of arterial hypertension (WHO-ISH recommendations, 1999).
These recommendations for the management of patients with hypertension were developed by experts from the Section on Arterial Hypertension of the All-Russian Scientific Committee on the basis of international standards, taking into account the prevalence of hypertension in Russia, local medical traditions, specific terminology, economic conditions and social factors. They are intended for practitioners directly involved in the management of patients with arterial hypertension. The recommendations contain sections on modern diagnosis and classification of hypertension, including rules for measuring blood pressure, standards for establishing and formulating a diagnosis, and determining the stage of the disease, which is important not only for developing tactics for managing a particular patient, but also for improving the quality of national statistics data regarding the pathology in question. The recommendation provides information on risk stratification of patients depending on blood pressure levels, the presence of other risk factors and concomitant conditions, which is new to our clinical practice. Finally, specific algorithms for patient management are provided taking into account the level of cardiovascular risk, the principles of drug therapy are discussed, as well as measures for the treatment of severe forms of hypertension and related emergency conditions.
Table 1. Diagnosis of secondary hypertension (methods for specifying a specific form)

Form AG	Basic diagnostic methods
Renal
Renovascular hypertension	Infusion renography
	Renal scintigraphy
	Doppler study of blood flow in the renal vessels
	Aortography
	Separate determination of renin during catheterization of the renal veins
Chronic glomerulonephritis	Kidney biopsy
Chronic pyelonephritis	Infusion urography
	Urine cultures
Endocrine
Primary hyperaldosteronism (Conn's syndrome)	Tests with hypothiazide and veroshpiron
	Determination of aldosterone levels and plasma renin activity
	Computed tomography of the adrenal glands
Cushing's syndrome or disease	Determining the level of cortisol in the blood
	Determination of the level of excretion of oxycorticosteroids in urine
	Test with dexamethasone
	Imaging of the adrenal glands and pituitary gland (ultrasound, computed tomography)
Pheochromocytoma	Determination of the level of catecholamines and their metabolites in the blood and urine
	Tumor visualization (CT - computed tomography, NMR - nuclear
	Magnetic resonance, scintigraphy)
Hemodynamic hypertension
Coarctation of the aorta	Doppler ultrasound, aortography
AH in organic lesions of the nervous system	Individually as prescribed by a specialist
Iatrogenic hypertension	Decrease in blood pressure when discontinuing the drug (if possible)

Definition and classification of hypertension
The term “hypertension” (HTN), which, according to WHO decision, corresponds to the concept of essential hypertension used in other countries, was proposed by G.F. Lang. Hypertension is usually understood as a chronic disease, the main manifestation of which is the syndrome of arterial hypertension, which is not associated with the presence of pathological processes in which the increase in blood pressure is due to known causes (symptomatic arterial hypertension).
Diagnosis of hypertension when examining patients with hypertension is carried out in a strict sequence, meeting certain objectives.
Statement of hypertension – it is necessary to confirm the presence of hypertension.
According to unified international criteria (according to WHO-IOG, 1999), arterial hypertension is defined as a condition in which blood pressure is 140 mmHg. Art. or higher and/or blood pressure - 90 mm Hg. Art. or higher in persons who are are not currently receiving antihypertensive therapy.
The accuracy of blood pressure measurement and, accordingly, the correct diagnosis depends on compliance with the rules for measuring blood pressure.

Table 2. Definition and classification of blood pressure levels (WHO-IOG, 1999)

Category	Blood pressure (mmHg)	ADD (mm Hg)
Normal blood pressure
Optimal	< 120	< 80
Normal	< 130
High normal	130-139	85-89
Arterial hypertension
Hypertension 1st degree ("mild")	140-159	90-99
Subgroup: borderline	140-149	90-94
Hypertension grade 2 (“moderate”)	160-179	100-109
Hypertension grade 3 ("severe")	i 180	і 110
Isolated systolic hypertension	і 140	< 90
Subgroup: borderline	140-149	< 90

Table 3. Distribution of patients with hypertension according to risk level for quantitative assessment of prognosis

Blood pressure level (mm Hg)
Other risk factors plus medical history	Degree 1 (mild hypertension or ADD 90-99 ADD 140-159	Degree 2 (moderate hypertension (BP 160-179 or BP 100- 109	Grade 3 (severe hypertension) ADSі 180 or ADD Ћ 110
I. HD I without other risk factors	low risk	average risk	High risk
II. HD I + 1-2 risk factors	average risk	average risk	Very high risk
III. HD I + 3 or more risk factors or HD II and diabetes	high risk	high risk	Very high risk
IV. HD III and DM with nephropathy	very high risk	very high risk	Very high risk
Risk levels (risk of stroke or myocardial infarction over 10 years): Low risk = less than 15%; average risk = 15-20%; high risk = 20-30%; very high risk = 30% or higher.

Rules for measuring blood pressure
To measure blood pressure, the following conditions are important:
1. Position of the patient

• Sitting with emphasis, comfortable;
• hand on the table, fixed;
• the cuff is at the level of the heart, 2 cm above the elbow.

2. Circumstances

• Do not drink coffee for 1 hour before the test;
• do not smoke for 15 minutes;
• the use of sympathomimetics, including nasal and eye drops, is excluded;
• at rest after a 5-minute rest.

3. Equipment

• Cuff. The appropriate cuff size should be selected (the rubber part should be at least 2/3 of the length of the forearm and at least 3/4 of the circumference of the arm).
• The tonometer must be checked every 6 months; the position of the mercury column or the tonometer needle must be at zero before starting the measurement.

4. Measurement ratio

• To assess blood pressure levels, at least 3 measurements should be taken with an interval of at least 1 minute, if the difference is more than 5 mm Hg. Art. additional measurements are taken. The average of the last 2 measurements is taken as the final value.
• To diagnose the disease, at least 3 measurements must be taken with a difference of at least 1 week.

5. The actual measurement

• Quickly inflate the cuff to a pressure level of 20 mm. rt. Art. exceeding systolic (by disappearance of the pulse).
• Reduce cuff pressure at a rate of 2–3 mmHg. Art. in 1 s.
• The pressure level at which 1 Korotkoff sound appears corresponds to systolic blood pressure.
• The pressure level at which the sounds disappear (phase 5 of Korotkoff sounds) is taken as diastolic pressure.
• If the tones are very weak, then you should raise your hand and bend and straighten it several times; then the measurement is repeated. Do not apply too much pressure to the artery with the membrane of the phonendoscope.
• Initially, you should measure the pressure on both arms.
• Subsequently, measurements are taken on the arm where the blood pressure is higher.
• In patients over 65 years of age, with diabetes mellitus and receiving antihypertensive therapy, the measurement should also be taken while standing after 2 minutes.

Home blood pressure measurement
The values ​​of normal blood pressure levels and criteria for the classification of hypertension were introduced on the basis of blood pressure measured at a doctor’s appointment. Blood pressure measured at home can be a valuable addition to monitoring the effectiveness of treatment, but cannot be equated with data obtained in the clinic and requires the use of different standards. The use of currently available automatic and semi-automatic devices for home use that measure blood pressure on the fingers and forearm should be avoided due to the inaccuracy of the blood pressure values ​​obtained.

Drug class	Absolute readings	Relative readings	Absolute contraindications	Relative contraindications
Diuretics	Heart failure	Diabetes	Gout	Dyslipidemia
	Elderly patients			Preserved sexual activity in men
	Systolic hypertension
b-blockers	Angina pectoris	Heart	Asthma and chronic	Dyslipidemia
	Previous heart attack	failure	Obstructive bronchitis	Athletes and physically active patients.
	myocardium	Pregnancy	Blockade of the heart's pathways A
	Tachyarrhythmias	Diabetes		Peripheral vascular diseases
ACE inhibitors	Heart failure		Pregnancy
	Left ventricular dysfunction		Hyperkalemia
	Previous myocardial infarction
	Diabetic nephropathy
Calcium antagonists	Angina pectoris	Peripheral lesions vessels	Blockage of the heart pathways b	Congestive heart
	Elderly patients			Failure V
	Systolic hypertension
a -adrenergic blockers	Prostatic hypertrophy	Impaired glucose tolerance		Orthostatic hypotension
		Dyslipidemia
Angiotensin II antagonists	Cough while taking ACE inhibitors	Heart failure	Pregnancy
			Bilateral renal artery stenosis
			Hyperkalemia
a - Atriventricular block of 2 or 3 degrees
b - Atrioventricular block 2 or 3 degrees for verapamil or diltiazem
c - Verapamil or diltiazem

24-hour blood pressure monitoring
Daily ambulatory blood pressure monitoring does not replace one-time measurements, but provides important information about the state of the mechanisms of cardiovascular regulation, in particular, it identifies such phenomena as daily blood pressure variability, nocturnal hypotension, blood pressure dynamics over time and the uniformity of the hypotensive effect of antihypertensive drugs or combination therapy. At the same time, data from 24-hour blood pressure measurements have greater prognostic value than its one-time measurement. This method is important in making a diagnosis in case of unusual blood pressure variability during visits to the doctor, if “white coat hypertension” is suspected, and can also provide significant assistance in selecting therapy. At the same time, although it is absolutely informative, the method of 24-hour blood pressure monitoring is currently not generally accepted for establishing the diagnosis of hypertension and does not have standards for assessing the results.
After establishing the presence of hypertension, the patient should be examined to determine the etiology of the disease. Hypertension is diagnosed when symptomatic hypertension is excluded.
Next, the stage of the disease and the level of individual risk are determined. At this stage of diagnosis, the diagnosis of a particular patient is formulated and his risk group is assessed, which determines the further approach to patient management. Thus, examination of a patient with hypertension poses the following tasks:

• Exclusion of symptomatic hypertension or identification of its type.
• Determining the presence of target organ lesions and quantifying their severity, which is important for determining the stage of the disease.
• Determination of the severity of hypertension by blood pressure level.
• Identification of the presence of other risk factors for cardiovascular diseases and clinical conditions that may affect prognosis and treatment, classifying the patient into a particular risk group.
• The examination includes 2 stages.
  The first stage is mandatory research, which is carried out for each patient when hypertension is detected. This stage includes screening methods for diagnosing secondary hypertension, basic methods for identifying target organ damage performed for all forms of hypertension, as well as diagnosing the most important concomitant clinical conditions that determine the risk of cardiovascular complications.
  1. History taking
  A patient with newly diagnosed hypertension requires a thorough history taking, which should include:
• Family history of hypertension, diabetes mellitus, lipid disorders, coronary heart disease (CHD), stroke or kidney disease.
• Duration of existence of hypertension and levels of increased blood pressure in the anamnesis, as well as the results of previously used antihypertensive drugs, the presence of a history of hypertensive crises.
• Data on the presence in history and current symptoms of coronary artery disease, heart failure, central nervous system diseases, peripheral vascular lesions, diabetes mellitus, gout, lipid metabolism disorders, broncho-obstructive diseases, kidney diseases, sexual disorders and other pathologies, as well as information on medications, used to treat these diseases, especially those that may increase blood pressure.
• Identification of specific symptoms that would give reason to assume the secondary nature of hypertension.
• In women - a gynecological history, the connection between increased blood pressure and pregnancy, menopause, taking hormonal contraceptives, and hormone replacement therapy.
• A thorough assessment of lifestyle, including consumption of fatty foods, table salt, alcoholic beverages, smoking and physical activity, and data on changes in body weight over the lifespan.
• Personal and psychological characteristics, as well as environmental factors that could influence the course and outcome of treatment of hypertension, including marital status, situation at work and in the family, level of education.

2. Objective research

It is necessary to conduct a complete objective study, which should include the following important elements:

• measurement of height and weight with calculation of body mass index (weight in kilograms divided by the square of height in meters);
• assessment of the state of the cardiovascular system, in particular, the size of the heart, the presence of pathological noises, manifestations of heart failure (wheezing in the lungs, edema, liver size), detection of pulse in the peripheral arteries and symptoms of coarctation of the aorta (in patients under 30 years of age, blood pressure must be measured at legs);
• identification of pathological noises in the projection of the renal arteries, palpation of the kidneys and identification of other space-occupying formations.

3. Laboratory and instrumental studies (mandatory)

• General urine test (at least 3).
• Potassium, fasting glucose, creatinine, total blood cholesterol.
• ECG.
• Chest X-ray.
• Fundus examination.
• Ultrasound of the kidneys.

If at this stage of the examination the doctor has no reason to suspect the secondary nature of hypertension (or it can already be diagnosed with confidence, for example, polycystic kidney disease) and the available data is sufficient to determine the patient’s risk group and, accordingly, treatment tactics, then the examination may be completed finished.
The second stage is optional (additional studies

• Special examinations to detect secondary hypertension.

If a secondary nature of hypertension is suspected, targeted studies are performed to clarify the nosological form of hypertension and, in some cases, the nature and/or localization of the pathological process. In table Table 1 provides the main methods for clarifying the diagnosis for various forms of symptomatic hypertension. The most informative diagnostic methods in each case are highlighted in bold.

• Additional studies to assess associated risk factors and target organ damage are performed in cases where they may affect patient management:
• Lipid spectrum and triglycerides.
• Echocardiography as the most accurate method for diagnosing LVH. LVH is not detected on an ECG, and its diagnosis will affect the decision on prescribing therapy.

If a patient has hypertension, the stage of the disease should be determined. In Russia, the use of a 3-stage classification of the disease, based on damage to “target organs” (WHO, 1962), remains relevant. It should be noted that a number of points regarding the basis for establishing the stage of the disease have been significantly changed compared to the old classification, which is dictated by a significant expansion of ideas about the interaction of hypertension with other factors.
Stage 1 hypertension presupposes the absence of changes in the “target organs” detected by the above examination methods.
Stage II hypertension involves the presence of one and/or several changes in target organs:

• Left ventricular hypertrophy (ECG, radiography, echocardiography).
• Proteinuria and/or slight increase in creatinine concentration (0.13–0.2 mmol/l).
• Ultrasound or radiological evidence of the presence of atherosclerosis of the carotid, iliac and femoral arteries, and aorta.
• Retinal angiopathy.

Stage III hypertension is diagnosed in the presence of one and/or more of the following signs:

• Acute cerebrovascular accident (ACVA) (ischemic stroke or cerebral hemorrhage) or a history of dynamic cerebrovascular accident.
• Previous myocardial infarction, existing angina and/or congestive heart failure.
• Renal failure (plasma creatinine concentration > 0.2 mmol/l).
• Vascular pathology
• dissecting aneurysm;
• obliterating atherosclerosis of the arteries of the lower extremities with clinical manifestations.
• Hypertensive retinopathy of high grades (hemorrhages or exudates, swelling of the optic nerve nipple).

The establishment of stage III of the disease in this classification does not so much reflect the development of the disease over time and the cause-and-effect relationship between hypertension and existing heart pathology (in particular angina), but rather indicates the severity of structural and functional disorders in the cardiovascular system. The presence of the above manifestations on the part of organs and systems automatically places the patient in a more severe risk group and therefore requires establishing the most severe stage of the disease, even if changes in this organ are not, in the doctor’s opinion, a direct complication of hypertension. At the same time, the level of pressure increase itself is not taken into account in this classification, which is its significant drawback.

Determination of the severity of hypertension
Today, the classification of hypertension and, accordingly, hypertension, which is carried out on the basis of taking into account the level of blood pressure, is becoming increasingly important. WHO-ITF experts preferred the terms “grade” 1, 2 and 3 over the terms “stage”, since the word “stage” implies progression over time, which, as already noted, is not always true. The classification of blood pressure levels in adults over 18 years of age is presented in Table. 2. The terms “mild”, “moderate” and “severe” from previous versions of the WHO-ITF Guidelines are the same as grades 1, 2 and 3, respectively. The previously widely used term “borderline hypertension” has become a subgroup of grade 1 hypertension.
If the value of ADC or ADD falls into 2 adjacent categories at once, then the patient should be classified in a higher category. When formulating a diagnosis of hypertension, it is desirable to indicate not only the stage of the disease, but also the degree of severity. In addition, due to its importance for prognosis, it is recommended to indicate the presence of clinically significant target organ damage.
Examples of the formulation of the diagnosis (mandatory formulations are indicated in bold, other points are indicated at the discretion of the doctor, but are desirable).
Hypertension stage II . Severity level 2. Left ventricular hypertrophy.
Severity level 3. IHD. Angina pectoris II stage. class
Hypertension, stage II. Severity level 1. Atherosclerosis of the aorta, carotid arteries.
Hypertension stage III. Severity level 3. Obliterating atherosclerosis of the vessels of the lower extremities. Intermittent claudication.
Distribution of patients by absolute level of risk of cardiovascular diseases
The decision to manage a patient with arterial hypertension should be made not only on the basis of blood pressure levels, but also necessarily taking into account the presence of other risk factors and concomitant diseases, such as diabetes mellitus, target organ pathology, cardiac-vascular and renal lesions. It is also necessary to take into account certain aspects of the patient's personal, clinical and social situation. To assess the cumulative impact of several risk factors relative to the absolute risk of severe cardiovascular damage in the future, WHO-IOG experts proposed risk stratification into four categories (low, moderate, high and very high risk - Table 3). The risk in each category was calculated based on data on the 10-year average risk of death from cardiovascular diseases, the risk of non-fatal stroke and myocardial infarction according to the results of the Framingham Study. To determine the risk group, you need to know the stage of the disease, the degree of increase in blood pressure and the main factors listed below.

I. Factors influencing the prognosis of a patient with hypertension and used to determine the risk group.
Risk factors

• Levels of ADS and ADD (grades 1–3)
• Men > 55 years old
• Women > 65 years old
• Smoking
• Total cholesterol > 6.5 mmol/l
• Diabetes
• Cases of early manifestations of cardiovascular pathology in a family history (stroke or heart attack before the age of 50 years)

Target organ damage

• Left ventricular hypertrophy (ECG, echocardiography, radiography). Proteinuria and/or increased creatinine concentration (1.2–2.0 mg/dL)
• Ultrasound or radiological evidence of the presence of atherosclerotic plaque (carotid, iliac and femoral arteries, aorta)
• Generalized or general narrowing of the retinal arteries

Concomitant clinical pathology

Pathology of cerebral vessels

• Ischemic stroke
• Brain hemorrhage
• Transient cerebrovascular accident

Heart pathology

• Myocardial infarction
• Angina pectoris
• Revascularization of coronary vessels

Kidney pathology

• Diabetic nephropathy
• Renal failure (plasma creatinine concentration > 2.0 mg/l)
• Vascular pathology
• Dissecting aneurysm
• Pathology of arteries with clinical symptoms

High grade hypertensive retinopathy

• Hemorrhages or exudates
• Papilledema

II. Other factors that negatively affect the prognosis of a patient with hypertension.

• Reduced high-density lipoprotein (HDL) cholesterol
• Elevated low-density lipoprotein (LDL) cholesterol
• Microalbuminuria in diabetes mellitus
• Impaired glucose tolerance
• Obesity
• Sedentary lifestyle
• Increased fibrinogen levels

The role of these factors is currently considered significant, but they are not used for risk stratification and their assessment is optional.

Treatment
Goals of therapy
The main goal of treating a patient with hypertension is to achieve the maximum degree of reduction in the overall risk of cardiovascular morbidity and mortality. This involves addressing all identified reversible risk factors such as smoking, high cholesterol and diabetes mellitus, appropriate treatment of concomitant diseases, as well as correction of high blood pressure itself. The activity of the clinician when treating a patient with hypertension should increase taking into account the number and severity of risk, the presence of concomitant pathology and the overall degree of risk of severe cardiovascular diseases, in accordance with Table. 3.
Since the relationship between cardiovascular risk and blood pressure is linear, the goal of antihypertensive therapy should be to reduce blood pressure to levels defined as “normal” or “optimal” (Table 2). For young and middle-aged patients, as well as for patients with diabetes, it is advisable to reduce blood pressure below 130/85 mmHg Art., and for elderly patients it is advisable to achieve at least high normal blood pressure values ​​(below 140/90 mm Hg).

General principles of patient management

• If the patient is classified as high or very high risk, immediate medication management for hypertension and other risk factors or comorbidities should be prescribed.
• Since the group of patients at average risk is extremely heterogeneous in terms of blood pressure levels and the nature of risk factors, the decision on the timing of initiation of drug therapy is made by the doctor. It is acceptable to monitor blood pressure for several weeks (up to 3–6 months) to make a decision on prescribing drug therapy. It should be started when blood pressure remains above 140/90 mm Hg. Art.
• In the low-risk group, long-term observation of the patient (6–12 months) should be carried out before deciding whether to prescribe drug therapy. Drug therapy in this group is prescribed when blood pressure remains at 150/95 mmHg. Art. and higher.

A practical scheme for managing a patient with grade 1–2 hypertension is presented in the figure.
Lifestyle changes are recommended for all patients, including those receiving drug therapy, especially in the presence of certain risk factors. They allow:

• reduce blood pressure levels in each individual patient;
• reduce the need for antihypertensive drugs and maximize their effectiveness;
• influence other existing risk factors;
• carry out primary prevention of hypertension and reduce the risk of concomitant cardiovascular disorders at the population level.

They include:

• To give up smoking
• Weight loss
• Reducing alcohol consumption
• Increased physical activity
• Reducing salt intake
• A comprehensive change in diet (increasing consumption of plant foods, reducing consumption of saturated fats, increasing potassium, calcium and magnesium in the diet).

Principles of drug therapy

• use low doses of antihypertensive drugs at the initial stage of treatment, starting with the lowest dosage of the drug in order to reduce adverse side effects. If there is a good response to a low dose of this drug, but blood pressure control is still insufficient, it is advisable to increase the dosage of this drug if it is well tolerated;
• use effective combinations of small doses of antihypertensive drugs to maximize blood pressure reduction with minimal side effects. This means that if one drug is ineffective, preference is given to adding a small dose of a second drug rather than increasing the dosage of the original one. In this context, the use of fixed low doses in combinations, which are increasingly used in the world, is convenient and promising;
• carry out a complete replacement of one class of drug with another class of drugs in case of low effect or poor tolerability without increasing its dosage or adding another drug;
• use long-acting drugs that provide an effective reduction in blood pressure for 24 hours with a single daily dose. This reduces the range of blood pressure fluctuations, improves the quality of disease control and contributes to a greater extent to reducing cardiovascular risk.

Currently, any of the 6 main classes of antihypertensive drugs presented in Table 1 can be used to start treatment of patients with hypertension. 4. The choice of a specific drug is influenced by many factors, among which the most important are the following:

• existing risk factors for the patient;
• the presence of damage to target organs, clinical manifestations of cardiovascular diseases, kidney diseases and diabetes mellitus;
• the presence of concomitant diseases that may promote or limit the use of an antihypertensive drug of one class or another;
• individual reactions of patients to drugs of various classes;
• the likelihood of interaction with drugs that the patient uses for other reasons;
• the cost of treatment and, related to this, its availability.

Other drugs
The use of centrally acting drugs such as clonidine, reserpine, methyldopa is recommended as reserve therapy, since they have a fairly large number of side effects. More promising as drugs of choice when starting treatment for a patient with hypertension are new drugs from this group - imidazoline receptor agonists - moxonidine and rilmenidine, which cause significantly less side effects.
If, for reasons of cost of treatment, neurotropic drugs are used as the first line, their doses should be reduced and combinations with other antihypertensive drugs (diuretics) should be used.
The use of direct vasodilators (hydralazine, minoxidil) is also not recommended as first line of therapy.

Combination therapy
The use of drugs of the main classes in recommended doses for monotherapy ensures a reduction in blood pressure by an average of 7–3 mm Hg. Art. for systolic and 4–8 mmHg. Art. for diastolic blood pressure. Moreover, a decrease in blood pressure to normal values ​​with monotherapy can be achieved only in 30% of patients (results of the NOT study, 1998).
Therefore, most patients are treated with combination therapy, which causes a more effective reduction in blood pressure compared to monotherapy (2 times or more).
Effective drug combinations

• diuretic and b-blocker.
• diuretic and ACE inhibitor (or AII antagonist).
• calcium antagonist (dihydropyridine) and b-blocker.
• calcium antagonist and ACE inhibitor.
• a-blocker and b-blocker.
• Centrally acting drug and diuretic.

Effective combinations use drugs from different classes to achieve complementary effects by combining drugs with different mechanisms of action while minimizing interactions that limit blood pressure reduction.

Dynamic surveillance

• Achieving and maintaining target blood pressure levels requires dynamic monitoring of the patient with monitoring of compliance with recommendations for lifestyle changes, regularity of antihypertensive therapy and its correction depending on the effectiveness and tolerability of treatment. During dynamic observation, the achievement of individual contact between the patient and the doctor and a patient education system that increases the patient’s susceptibility to treatment are crucial.
• After starting therapy for a patient with hypertension, a follow-up visit is necessary (no more than 1 month later) to monitor the adequacy of treatment, the presence of side effects, and the patient’s correct compliance with recommendations.
• If blood pressure control is achieved, then further visits to the doctor to monitor the effectiveness of therapy and risk factors are prescribed once every 3 months in patients with high and very high risk and once every 6 months in patients with average and low risk.
• If therapy is insufficiently effective or sensitivity to the drug decreases, it is replaced or another drug is added, with subsequent monitoring no more than 1 month later.
• If there is no proper antihypertensive effect, it is possible to add a 3rd drug (one of the drugs in this case should be a diuretic) with subsequent monitoring.
• In patients at high and very high risk, treatment can begin immediately with the use of 2 drugs, and the intervals between visits for dose titration and intensification of therapy should be reduced.
• In case of so-called “resistant hypertension” (if a reduction in blood pressure of less than 140/90 is not achieved during therapy with 3 drugs in submaximal doses), one should make sure that there are no objective reasons for resistance (undiagnosed secondary hypertension, non-compliance by the patient with the drug regimen or lifestyle recommendations , for example, excessive salt intake, taking concomitant medications that weaken the effect of therapy, incorrect blood pressure measurement (inadequate cuff size).In the case of truly resistant hypertension, the patient should be referred for treatment to a specialized department.

With stable normalization of blood pressure (over the course of a year and compliance with lifestyle changes in patients in low- and medium-risk groups, a gradual reduction in the number and dose of drugs used is possible. When reducing the dose or reducing the number of drugs used, the frequency of visits to the doctor should be increased, in order to to make sure there is no increase in blood pressure.
Treatment of arterial hypertension in separate groups of patients. hypertension in the elderly

• The results of randomized trials have demonstrated the positive effects of treatment in elderly patients with classic systolic-diastolic hypertension, as well as in patients with isolated systolic hypertension up to 80 years of age. The absolute effects of treatment in older age groups require clarification.
• Treatment of hypertension in elderly patients should also begin with lifestyle changes. Limiting table salt and reducing weight in this group has a significant antihypertensive effect.
• The initial dose of all drugs in elderly patients should be halved, and during observation, attention should be paid to the possibility of orthostatic hypotension. Caution should be used when using drugs that cause significant vasodilation, such as alpha blockers, direct vasodilators, and high doses of diuretics..
• When choosing a drug, preference is given to diuretics, especially in systolic hypertension, as well as small doses of beta blockers. Alternative drugs are long-acting calcium antagonists or ACE inhibitors.

Pregnancy

• Hypertension during pregnancy is defined either by the absolute level of blood pressure (for example, > 140/90 mm Hg or higher) or by the rise in blood pressure compared to the level before conception or during the first trimester (for example, a rise in blood pressure of ≤ 25 mm Hg . and/or rise in blood pressure ≤ 15 mm Hg). Hypertension in pregnant women is divided into chronic hypertension or secondary hypertension.

With preeclampsia, blood pressure increases above 170/110 mmHg. Art. requires therapeutic measures to reduce it in order to protect the mother from the risk of stroke or eclampsia. Drugs that are used to rapidly lower blood pressure include nifedipine, labetolol and hydralazine. The use of magnesium sulfate alone for the treatment of severe hypertension in pregnant women is ineffective.

• For the ongoing treatment of arterial hypertension in pregnant women, antihypertensive drugs such as b -blockers, in particular atenolol (associated with fetal growth restriction in conditions of long-term use throughout pregnancy), methyldopa, labetolol, doxazosin, hydralazine, nifedipine.
• The drug of choice for the treatment of hypertension in pregnant women is methyldopa.
• The following drugs are not recommended during pregnancy: ACE inhibitors, which have a teratogenic effect, and AII receptor antagonists, the effects of which are likely to be similar to those of ACE inhibitors. Diuretics should be used with caution as they may further reduce the already altered blood plasma volume.

Some aspects of the treatment of hypertension in women

• The general principles of therapy, prognosis and effectiveness of individual drugs do not have significant gender differences.
• Women taking oral contraceptives are more likely to develop hypertension, especially in combination with obesity, in smokers and at older ages. If hypertension develops while taking these drugs, they should be discontinued.
• Hypertension is not a contraindication to hormone replacement therapy in postmenopausal women. However, when starting hormone replacement therapy, blood pressure should be monitored more often, as it may increase.

Vascular lesions of the brain
In persons with a history of stroke or transient cerebrovascular accident, the risk of further similar manifestations is very high (up to 4% per year). Antihypertensive therapy reduces the risk of stroke by 29%. Blood pressure reduction should be carried out gradually until minimum tolerable levels are reached. Monitor for the possibility of orthostatic hypotension.

Hypertension in combination with coronary heart disease

• The combination of hypertension and coronary artery disease dramatically increases the risk of serious complications and mortality.

Beta-blockers and ACE inhibitors should be used as antihypertensive therapy in the absence of contraindications. Calcium channel blockers, with the exception of short-acting ones, can also be used.

• In patients who have had myocardial infarction (MI), beta-blockers without intrinsic sympathomimetic activity and ACE inhibitors should be used, especially in the presence of heart failure (HF) or systolic dysfunction.
• If beta blockers are ineffective, intolerant, or have contraindications, verapamil or diltiazem are used.
• In general, in this category of patients, drugs that cause a rapid decrease in blood pressure, especially accompanied by reflex tachycardia, should be avoided.

Congestive heart failure

• Patients with congestive heart failure and hypertension are at particularly high risk of death from cardiovascular disease.
• The use of ACE inhibitors in patients with heart failure or left ventricular dysfunction significantly reduces mortality in this group of patients and is preferable. If ACE inhibitors are intolerant, AII receptor antagonists can be used.
• It is advisable to use diuretics according to indications in combination with ACE inhibitors.
• In recent years, the feasibility and effectiveness of the use of beta-blockers in patients with congestive heart failure has been shown.

Kidney diseases

• Arterial hypertension is a decisive factor in the progression of renal failure of any etiology, and adequate blood pressure control slows down its development.
• All classes of drugs and their combinations can be used to treat hypertension in kidney diseases. There is evidence that ACE inhibitors and calcium antagonists have an independent nephroprotective effect. When plasma creatinine levels are more than 0.26 mmol/l, the use of ACE inhibitors should be used with caution.
• In patients with renal failure and proteinuria, antihypertensive therapy should be carried out more aggressively. In patients with protein loss > 1 g/day, a lower target blood pressure level is set (125/75 mm Hg) than in patients with less severe proteinuria (130/80 mm Hg).

Diabetes

• The incidence of arterial hypertension in patients with diabetes is 1.5–2 times higher than in persons without diabetes. The presence of both diabetes mellitus and hypertension deserves special attention, since both pathologies are risk factors for many macro- and microvascular lesions, leading to an increased risk of coronary artery disease, congestive heart failure, cerebral and peripheral vascular lesions, as well as death associated with cardiac pathology.
• Non-pharmacological interventions such as weight loss have been shown to improve insulin resistance and BP in diabetic patients with hypertension. Unidirectional lifestyle modification is recommended for the initial stages of treatment of both hypertension and diabetes mellitus, or their combination.
• For patients with diabetes of any age, the target blood pressure level is set to no higher than 130/85 mmHg. Art.
• When choosing a drug, preference is given to ACE inhibitors, especially in the presence of proteinuria, calcium antagonists and low doses of diuretics.
• Despite the possible negative effects on peripheral blood flow and the ability to prolong hypoglycemia and mask its symptoms, the use of beta blockers is recommended for patients with hypertension and diabetes, especially in combination with coronary artery disease and previous myocardial infarction, since their use improves the prognosis of these patients (UKPDS study, 1998) .
• When monitoring treatment, you should be aware of possible orthostatic hypotension.

Patients with bronchial asthma and chronic obstructive pulmonary diseases

• Beta blockers, even topical ones (timolol), are contraindicated in patients in this group.
• ACE inhibitors should be used with caution; in case of cough, they can be replaced with AII receptor antagonists.
• Drugs used to treat bronchial obstruction often lead to an increase in blood pressure. The safest in this regard are sodium cromoglycate, ipratropium bromide and inhaled glucocorticoids.

Emergency conditions in hypertension (hypertensive crisis, hypertensive encephalopathy)
All situations in which a rapid decrease in blood pressure is required to one degree or another are divided into two large groups.
1. Conditions requiring emergency treatment (lowering blood pressure within the first minutes and hours using parenterally administered drugs).

• Emergency treatment requires an increase in blood pressure that leads to the appearance or worsening of symptoms from target organs - unstable angina, myocardial infarction, acute left ventricular failure, dissecting aortic aneurysm, eclampsia, stroke, papilledema. An immediate reduction in blood pressure may also be required in case of injury to the central nervous system, in postoperative patients with a risk of bleeding, etc.

Parenteral drugs for the treatment of crises include the following:
Vasodilators

• sodium nitropruside (may increase intracranial pressure)
• nitroglycerin (preferred for myocardial ischemia)
• enalapril (preferred in the presence of heart failure)

Antiadrenergic drugs

• esmolol
• phentolamine (if pheochromocytoma is suspected)

Diuretics (furosemide)
Ganglioblockers

Neuroleptics (droperidol)
Blood pressure should be reduced by 25% of baseline in the first 2 hours and to 160/100 mm Hg. Art. over the next 2–6 hours. Blood pressure should not be reduced too quickly to avoid ischemia of the central nervous system, kidneys and myocardium. Measurement of blood pressure at levels above 180/120 mmHg. Art. should be performed every 15–30 minutes.

2. Conditions that require a gradual decrease in blood pressure over several hours.
In itself, a sharp increase in blood pressure, not accompanied by the appearance of symptoms from other organs, requires mandatory, but not so urgent, intervention and can be stopped by oral administration of drugs with a relatively rapid action (beta blockers, calcium antagonists (nifedipine), clonidine, short-acting ACE inhibitors , loop diuretics, prazosin).
Treatment of a patient with an uncomplicated hypertensive crisis can be carried out on an outpatient basis. And only if the picture of a hypertensive crisis persists, or its course is complicated, the patient should be hospitalized in a hospital. Conditions requiring relatively urgent intervention include malignant hypertension(ZAG).
This syndrome is understood as a state of extremely high blood pressure (usually blood pressure exceeds 120 mm Hg) with the development of pronounced changes in the vascular wall, which leads to tissue ischemia and dysfunction of organs, in particular, to swelling of the optic nerve nipple. Activation of multiple hormonal systems is involved in the development of PAH, which leads to increased natriuresis, hypovolemia, as well as endothelial damage and proliferation of intimal SMCs. All these changes are accompanied by a further release of vasoconstrictors and an even greater increase in blood pressure. Malignancy of the course is possible both with hypertension and with symptomatic hypertension.
ZAG syndrome is usually manifested by the progression of renal failure, decreased vision, weight loss, symptoms from the central nervous system, changes in the rheological properties of the blood, up to DIC syndrome and hemolytic anemia.
In patients with PAH, a combination of 3 or more drugs is required.
When treating severe hypertension, one should remember the possibility of excess sodium excretion, especially with intensive administration of diuretics, which is accompanied by further activation of the renin-angiotensin system and an increase in blood pressure.
A patient with a malignant course of hypertension should be hospitalized and once again specifically examined for the possibility of secondary hypertension.

Indications for hospitalization

• Uncertainty of the diagnosis and the need for special (usually invasive) studies to clarify the nature of hypertension.
• Difficulty in selecting drug therapy at the prehospital stage (frequent crises, treatment-resistant hypertension).

Indications for emergency hospitalization

• Hypertensive crisis that does not resolve at the prehospital stage.
• Hypertensive crisis with pronounced manifestations of hypertensive encephalopathy.
• Complications of hypertension requiring intensive care and constant medical supervision (stroke, subarachnoid hemorrhage, acute visual impairment, pulmonary edema).

Conclusion
The development and widespread implementation of recommendations for the diagnosis and treatment of hypertension are aimed primarily at ensuring that the results of scientific research can be fully implemented into practice and actually lead to an improvement in the health of the population. The publication of these recommendations can become part of a nationwide program to improve the quality of diagnosis and control of arterial hypertension, the main goal of which is to reduce cardiovascular morbidity and mortality associated with arterial hypertension. The objectives of the recommendations were also to integrate world experience in the treatment of this pathological condition and the currently available national achievements on the problem of hypertension and, in addition, an attempt to introduce standardization into domestic terminology, bringing it into line with the international one, but without changing traditional concepts.
The purpose of this document is to provide the practicing physician with information about the results of epidemiological and clinical studies, on the basis of which modern principles of patient management and prognosis assessment are formulated. At the same time, the recommendations do not so much regulate the activities of the clinician as present him with sound principles for the management of patients, without at all excluding the possibility of making individual decisions based on the clinical characteristics of the patient or social conditions. At that At the same time, without excluding a subjective assessment of a specific clinical situation, the recommendations call on practitioners to use global experience in their activities, limiting the possibility of making decisions based only on personal experience and subjective judgments. Only by using these recommendations in everyday clinical practice will it be possible to count on the real effect of their implementation.

Literature
1. Almazov V.A., Shlyakhto E.V. Hypertonic disease. Moscow, 2000; 118 p.
2. Makolkin V.I., Podzolkov V.I. Hypertonic disease. Moscow, 2000; 96 p.
3. Oganov R.G. The problem of controlling arterial hypertension among the population. Cardiology, 1994; 3:80–83.
4. Chalmers J. et al. WHO-ISH Hypertension guidelines Committee. 19 99 World Heath Organization - International Society of Hypertension guidelines for the Management of Hypertension. J Hypertens 1999; 17: 151–185.
5. Joint National Committee on detection, evaluation, and treatment of high blood pressure. The six report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure (JNC VI)//Arch Intern Med 1997; 157:2413–46.
6. Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Menard J, Julius S, Rahn KH, Wedel H. Westerink , for the HOT Study Group. Effects og intensive blood pressure lowering and low-bose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial//Lancet. 1998; 351:1755–62.
7. Heart outcome evaluations (HOPE) study investigators. Effects of angiotensin-converting enzyme in inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000; 342:145–53.
8. The guidelines Subconnittee of the WHO-ISH Mild Hypertension Liaison Committee. 1993 Guidelines for the management of mild Hypertension Memorandum from a World Health Organization - International Society of Hypertension Meeting//J. Hypertens. 1993; 11:905–18.
9. The Sixth Report of the Joint national committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Archives of Internal Medicine 1997; 157:2413–46.
10. UK Prospective Diabetes Study Group. Efficacy at atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS//Br. Med J 1998; 317:713–20.
11. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38//Br. Med J 1998; 317:703–13.
12. WHO Expert Committee. Hypertension Control. WHO Technical Repoet Series N 862. - Geneva: World Health Organization. 1996.
13. UKPDS and UKPDS 38//br Ved J 1998; 317:707–13.

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), Nechiporenko urine, ALT, AST, 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.

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 blood 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 established that night-time BP is a stronger predictor than daytime BP. 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 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 taking 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) revealed 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 mm Hg) 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 hospital) during antihypertensive therapy, the closer these values ​​​​are to the values ​​​​obtained during ambulatory monitoring, with the maximum similarity of results being achieved in 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 therapy 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 for 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.

Literature

1. European Society of Hypertension-European Society of Cardiology Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension // J. Hypertens. 2003. Vol. 21. P. 1011-1053.

2. Mancia G. De Backer G. Dominiczak A. et al. 2007 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).

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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 the patient's condition to worsen, 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 level of blood pressure and the tolerability of antihypertensive drugs. therapy. The use of a step-by-step 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 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 choice of various 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 with 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; go 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 effect of drugs on the pathogenetic mechanisms of the development of hypertension, 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 by transferring patients 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 cardiovascular complications (primary endpoint) compared with 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 increases 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 of randomized controlled clinical trials studying the triple combination 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); elderly 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 salt of perindopril arginine, 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 of 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, AK, ACE inhibitors (except Prestarium A), diuretics (except Arifon, Arifon Retard), centrally acting drugs, ARBs in the form of monotherapy or free combinations. In addition to previous antihypertensive therapy, all included in 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. (R

Arterial hypertension is a leading risk factor for the development of cardiovascular, cerebrovascular and renal diseases. Arterial hypertension, clinical recommendations will be provided in this article

Arterial hypertension is a leading risk factor for the development of cardiovascular, cerebrovascular and renal diseases. Arterial hypertension, clinical recommendations - we will provide in this article.

Definition of arterial hypertension

Arterial hypertension is a syndrome of increased systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg.

These blood pressure (BP) thresholds are based on the results of randomized controlled trials demonstrating the feasibility and benefit of treatment aimed at reducing these BP levels in patients with “hypertension” and “symptomatic hypertension.”

The term “hypertension” (HD), proposed by G.F. Lang in 1948, corresponds to the term “essential hypertension” (hypertension) used abroad.

Hypertension is usually understood as a chronic disease in which an increase in blood pressure is not associated with the identification of obvious causes leading to the development of secondary forms of arterial hypertension (AH).

Hypertension predominates among all forms of arterial hypertension, its prevalence is over 90%. Due to the fact that hypertension is a disease that has different course options, the term “arterial hypertension (hypertension)” is used in the literature instead of the term “hypertension.”

Etiology and pathogenesis of hypertension

The pathogenesis of hypertension is not fully understood. The hemodynamic basis of increased blood pressure is an increase in arteriolar tone, caused by hyperactivation of the sympathetic nervous system.

In the regulation of vascular tone, great importance is currently attached to mediators of nervous excitation, both in the central nervous system and in all parts of the transmission of nerve impulses to the periphery, i.e. to the vessels.

Catecholamines (primarily norepinephrine) and serotonin are of primary importance. Their accumulation in the central nervous system is an important factor maintaining a state of increased excitation of higher regulatory vascular centers, which is accompanied by an increase in the tone of the sympathetic nervous system. Impulses from sympathetic centers are transmitted by complex mechanisms.

At least three ways are indicated:

1. Along sympathetic nerve fibers.
2. By transmitting excitation along preganglionic nerve fibers to the adrenal glands with the subsequent release of catecholamines.
3. By stimulating the pituitary gland and hypothalamus with subsequent release of vasopressin into the blood.

Subsequently, in addition to the neurogenic mechanism, other mechanisms that increase blood pressure, in particular humoral ones, may additionally (sequentially) be activated. Thus, in hypertension, two groups of factors can be distinguished:

• neurogenic, influencing through the sympathetic nervous system a direct effect on the tone of arterioles,
• humoral, associated with the increased release of catecholamines and some other biologically active substances (renin, adrenal hormones, etc.), which also cause a pressor effect.

When considering the pathogenesis of hypertension, it is also necessary to take into account the disruption (weakening) of mechanisms that have a depressor effect (depressor baroreceptors, the humoral depressor system of the kidneys, angiotensinases, etc.). Violation of the ratio of the activity of pressor and depressor systems leads to the development of arterial hypertension.

Epidemiology of arterial hypertension

Arterial hypertension (hypertension) is a leading risk factor for the development of cardiovascular (myocardial infarction, stroke, coronary heart disease (CHD), chronic heart failure), cerebrovascular (ischemic or hemorrhagic stroke, transient ischemic attack) and renal diseases (chronic kidney disease).

Cardiovascular and cerebrovascular diseases, presented in official statistics as diseases of the circulatory system (CVD), are the leading causes of mortality in the Russian Federation, accounting for more than 55% of deaths from the total number of deaths from all causes.

In modern society, there is a significant prevalence of hypertension, amounting to 30-45% among the adult population, according to foreign studies, and about 40%, according to Russian studies.

In the Russian population, the prevalence of hypertension among men is slightly higher, in some regions it reaches 47%, while among women the prevalence of hypertension is about 40%.

Coding according to ICD 10

• Diseases characterized by high blood pressure (I10-I15)
• I10 – Essential (primary) hypertension
• I11–Hypertensive heart disease (hypertension with primary damage to the heart)
• I12 – Hypertensive disease with predominant kidney damage
• I13 – Hypertensive disease with predominant kidney damage
• I15 – Secondary hypertension.

Secondary hypertension

Classification

The classification of blood pressure levels in people over 18 years of age is presented in Table 1.

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

Blood pressure categories	GARDEN		DBP
Optimal	< 120	And	< 80
Normal	120 - 129	and/or	80 - 84
High normal	130 - 139	and/or	85 - 89
1st degree hypertension	140 - 159	and/or	90 - 99
2nd degree hypertension	160 - 179	and/or	100 - 109
3rd degree hypertension	> 180	and/or	> 110
Isolated systolic hypertension (ISAH)	> 140	And	< 90

Note. * - ISAG should be classified into 1st, 2nd, 3rd grades. according to the level of systolic blood pressure.

If the values ​​of SBP and DBP fall into different categories, then the degree of hypertension is assessed according to the higher category. The results of 24-hour blood pressure monitoring (ABPM) and blood pressure monitoring (ABPM) can help in the diagnosis of hypertension, but do not replace repeated BP measurements in a health care setting (office or clinic BP). The criteria for diagnosing hypertension based on the results of ABPM, ABPM and blood pressure measurements made by a doctor are different. The data is presented in the table

2. Particular attention should be paid to the threshold values ​​of blood pressure at which hypertension is diagnosed during the SCAD: SBP > 135 mm Hg. and/or DBP > 85 mm Hg.

Table 2 - Threshold blood pressure levels (mm Hg) for diagnosing arterial hypertension according to various measurement methods

Category	SBP (mmHg)		DBP (mmHg)
Office AD	>140	and/or	>90
Ambulatory blood pressure
Daytime (awake)	>135	and/or	>85
Night (sleep)	>120	and/or	>70
Daily allowance	>130	and/or	>80
SCAD	>135	and/or	>85

The criteria for high blood pressure are largely arbitrary, since there is a direct relationship between blood pressure levels and the risk of cardiovascular diseases (CVD). This relationship begins with relatively low values ​​- 110-115 mmHg. Art. for SBP and 7075 mm Hg. Art. for DBP.

In people over 50 years of age, SBP level is a better predictor of cardiovascular complications (CVC) than DBP, while in young patients, the opposite is true. In elderly and senile people, increased pulse pressure (the difference between SBP and DBP) has additional prognostic value.

In persons with a high normal blood pressure level, at a doctor's appointment, it is advisable to carry out ABPM and/or ABPM to clarify the blood pressure level (in conditions of daily activity), as well as dynamic monitoring of blood pressure.

Diagnostics

Diagnostics of hypertension and examination includes the following stages:

• clarification of complaints and collection of anamnesis;
• repeated blood pressure measurements;
• physical examination;
• laboratory and instrumental research methods: simpler at the first stage and more complex at the second stage of the examination (according to indications).

Determination of the degree and stability of the increase in blood pressure is recommended to be carried out by clinical (office) blood pressure measurement (Table 1) in patients with a newly detected increase in blood pressure.

History of arterial hypertension

Comments: Anamnesis collection includes collecting information about the presence of risk factors, subclinical symptoms of POM, a history of CVD, CVD, CKD and secondary forms of hypertension, as well as previous experience in the treatment of hypertension.

Physical examination

A patient with hypertension is aimed at identifying risk factors, signs of secondary forms of hypertension and organ damage. Measure height, body weight with calculation of body mass index (BMI) in kg/m2 (determined by dividing body weight in kilograms by height in meters squared) and waist circumference, which is measured in a standing position (the patient should only be wearing underwear, the measuring point is the middle of the distance between the top of the iliac crest and the lower lateral edge of the ribs), the measuring tape should be held horizontally.

• general blood and urine analysis;
• blood plasma glucose test (fasting);
• study of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG);
• study of potassium, sodium in blood serum;

Method of self-monitoring of blood pressure - blood pressure indicators obtained during SCAD can become a valuable addition to clinical blood pressure in diagnosing hypertension and monitoring the effectiveness of treatment, but require the use of other standards (Table 2).

The BP value obtained by the SCAD method correlates more closely with POM and disease prognosis than clinical BP, and its predictive value is comparable to the method of 24-hour BP monitoring after adjustment for gender and age.

It has been proven that the SCAD method increases patient adherence to treatment. A limitation of the use of the SCAD method is those cases when the patient is inclined to use the results obtained for independent correction of therapy.

It must be taken into account that it cannot provide information on blood pressure levels during “everyday” (real) daytime activity, especially in the working part of the population, and at night. For SCAD, traditional tonometers with dial gauges can be used, as well as automatic and semi-automatic devices for home use that have been certified.

To assess the level of blood pressure in situations of a sharp deterioration in the patient’s well-being outside of a hospital setting (while traveling, at work, etc.), we can recommend the use of wrist automatic blood pressure meters, but with the same rules for measuring blood pressure (2-3 multiple measurements, placing the hand at the level of the heart etc.). It should be remembered that blood pressure measured at the wrist may be slightly lower than blood pressure measured at the shoulder.

The method of 24-hour blood pressure monitoring has a number of specific advantages:

Only the ABPM method allows you to determine the daily rhythm of blood pressure, nocturnal hypotension or hypertension, blood pressure dynamics in the early morning hours, the uniformity and sufficiency of the antihypertensive effect of drugs.

Only devices that have successfully passed clinical trials according to international protocols confirming the accuracy of measurements can be recommended. When interpreting ABPM data, the main attention should be paid to the average blood pressure values ​​for the day, night and day; daily index (the difference between blood pressure during the day and night hours); the value of blood pressure in the morning; blood pressure variability, during daytime and night hours (std) and pressure load indicator (percentage of elevated blood pressure values ​​during daytime and night hours).

Clinical indications for the use of ABPM and SCAD for diagnostic purposes:

1. Suspicion of “white coat hypertension.”
2. Patients with stage 1 hypertension according to clinical blood pressure.
3. High clinical BP in individuals without POM and in individuals with low overall cardiovascular risk.
4. Suspicion of “masked” hypertension.
5. High normal clinical blood pressure.
6. Normal clinical blood pressure in individuals with POM and in individuals with high overall cardiovascular risk.
7. Detection of “white coat hypertension” in patients with hypertension.
8. Significant fluctuations in clinical blood pressure during the same or different visits to the doctor.
9. Autonomic, orthostatic, postprandial, drug-induced hypotension; hypotension during daytime sleep.
10. Increased clinical blood pressure or suspicion of preeclampsia in pregnant women.
11. Identification of true and false refractory hypertension.

Specific indications for ABPM:

1. Pronounced discrepancies between the level of clinical blood pressure and BPMS data.
2. Assessment of the circadian rhythm of blood pressure.
3. Suspicion of nocturnal hypertension or absence of nocturnal reduction in blood pressure, for example, in patients with sleep apnea, CKD or diabetes.
4. Assessment of blood pressure variability.

It is recommended to use CT or MRI in patients with hypertension in order to identify complications of hypertension (asymptomatic cerebral infarctions, lacunar infarctions, microhemorrhages and white matter lesions in discirculatory encephalopathy, previous transient ischemic attacks/stroke).

Assessment of general (total) cardiovascular risk

In asymptomatic hypertensive patients without cardiovascular disease, CKD or diabetes, risk stratification using the Systemic coronary risk evaluation (SCORE) model is recommended.

Comments: Detection of end-organ damage is recommended because there is evidence that end-organ damage is a predictor of cardiovascular mortality independent of SCORE.

Table 3 - Risk stratification in patients with arterial hypertension

Other risk factors asymptomatic target organ damage or associated diseases		Blood pressure (mmHg)
	Stage 1 hypertension SBP 140-159 or DBP 90-99	Stage 2 hypertension SBP 160-179 or DBP 100-109	Stage 3 hypertension SBP > 180 or DBP > 110
No other risk factors	Low risk	Medium risk	High risk
1-2 risk factors	Medium risk	High risk	High risk
3 or more risk factors	High risk	High risk	High risk
Subclinical POM, CKD stage 3. or SD	High risk	High risk	Very high risk
CVD, CVD, CKD>4 degrees. or diabetes with POM or risk factors	Very high risk	Very high risk	Very high risk

Note. BP - blood pressure, AH - arterial hypertension, CKD - ​​chronic kidney disease, DM - diabetes mellitus; DBP - diastolic blood pressure, SBP - systolic blood pressure.

Table 4 - Risk factors influencing prognosis, used to stratify overall cardiovascular risk

Risk factors	Characteristic
Floor	male
Age	>55 years for men, >65 years for women
Smoking	YES
Lipid metabolism	dyslipidemia (each of the presented indicators of lipid metabolism is taken into account)
Total cholesterol >4.9 mmol/L (190 mg/dL) and/or LDL cholesterol >3.0 mmol/L (115 mg/dL)	>4.9 mmol/L (190 mg/dL) and/or >3.0 mmol/L (115 mg/dL) and/or
High-density lipoprotein cholesterol	for men -<1,0 ммоль/л (40 мг/дл), у женщин - <1,2 ммоль/л (46 мг/дл)
Triglycerides	>1.7 mmol/l (150 mg/dl
Fasting plasma glucose	5.6-6.9 mmol/l (101-125 mg/dl)
Impaired glucose tolerance	7.8 - 11.0 mmol/l
Obesity	body mass index >30 kg/m2
Abdominal obesity	waist circumference: for men - >102 cm for women >88 cm (for people of the European race)
Family history of early cardiovascular disease	for men -<55 лет у женщин - <65 лет
Subclinical target organ damage
Pulse pressure (in persons elderly and senile age)	>60 mmHg
Electrocardiographic signs of LVH	Sokolov-Lyon index SV1+RV5-6>35 mm; Cornell indicator (RAVL+SV3)

	for men > 28 mm; for women > 20 mm, (RAVL+SV3), Cornell product (RAVL+SV3) mm x QRS ms > 2440 mm x ms
Echocardiographic signs of LVH	LVMM index: in men - >115 g/m2, in women - >95 g/m2 (body surface area)*
Thickening of the wall of the carotid arteries	intima-media complex > 0.9 mm) or plaque in brachiocephalic/renal/iliofemoral arteries
Pulse wave velocity (“carotid-femoral”)	>10 m/sec
Ankle-brachial systolic pressure index	<0,9 **
Chronic kidney disease	Stage 3 with eGFR 30-60 ml/min/1.73 m2 (MDRD formula) *** or low creatinine clearance<60 мл/мин (формула Кокрофта-Гаулта)**** или рСКФ 30-60 мл/мин/1,73 м2 (формула CKD-EPI)*****
Microalbuminuria	(30-300 mg/l) or albumin to creatinine ratio (30-300 mg/g; 3.4-34 mg/mmol) (preferably in morning urine)
Diabetes
Fasting plasma glucose and/or HbA1c and/or Plasma glucose after exercise	>7.0 mmol/L (126 mg/dL) on two consecutive measurements and/or >7% (53 mmol\mol) >11.1 mmol/l (198 mg/dl)
Cardiovascular, cerebrovascular or renal diseases
Cerebrovascular disease:	ischemic stroke, cerebral hemorrhage, transient ischemic attack
	myocardial infarction, angina pectoris, coronary revascularization using percutaneous coronary intervention or coronary artery bypass grafting
Heart failure	Stages 2-3 according to Vasilenko-Strazhesko

Formulation of diagnosis

When formulating a diagnosis, the presence of RF, POM, CVD, CVD, CKD and cardiovascular risk should be reflected as fully as possible. The degree of increase in blood pressure must be indicated in patients with newly diagnosed hypertension. If the patient is a patient, then the diagnosis indicates the degree of hypertension at the time of admission. The stage of the disease must also be indicated.

According to the three-stage classification of headache, stage I headache implies the absence of POM, stage II hypertension implies the presence of changes in one or more target organs. The diagnosis of hypertension stage is established in the presence of CVD, CVD, or CKD.

Table 5 - Patient management tactics depending on the total cardiovascular risk

Risk factors		(mmHg.)
	AG 1st degree 140159/90-99	AH 2nd degree 160179/100-109	Stage 3 hypertension >180/110
No risk factors	Lifestyle changes over several months If hypertension persists, prescribe drug therapy		Changing the image life Assign medicinal therapy
1-2 risk factors	Lifestyle changes over several weeks If hypertension persists, prescribe drug therapy	Changing the image life Assign medicinal therapy	Changing the image life Assign medicinal therapy
3 or more risk factors	Changing the image life Assign medicinal therapy	Changing the image life Assign medicinal therapy	Changing the image life Assign medicinal therapy

Treatment of arterial hypertension

Goals of therapy

The main goal of treatment of patients with hypertension is to minimize the risk of developing complications of hypertension: fatal and non-fatal CVD, CVD and CKD.

To achieve this goal, it is necessary to reduce blood pressure to target levels, correct all modifiable risk factors (smoking, dyslipidemia, hyperglycemia, obesity, etc.), prevent/slow down the rate of progression and/or reduce the severity (regression) of POM, as well as treat existing cardiovascular , cerebrovascular and renal diseases (Table 5).

The most important aspect for a patient with hypertension is to decide on the advisability of prescribing AHT. Indications for the use of antihypertensive drugs are determined individually based on the value of the total (total) cardiovascular risk (table 5).

Lifestyle interventions

Lifestyle changes are recommended for all patients with hypertension. Non-drug treatment methods for hypertension help lower blood pressure, reduce the need for antihypertensive drugs and increase their effectiveness, allow correction of risk factors, and primary prevention of hypertension in patients with high normal blood pressure and those with risk factors.

Comments: There is strong evidence of a link between salt intake and blood pressure levels. Excessive salt intake may play a role in the development of refractory hypertension. Standard salt intake in many countries ranges from 9 to 12 g/day (80% of salt consumed is the so-called “hidden salt”), reducing its intake to 5 g/day in patients with hypertension leads to a decrease in SBP by 4-5 mmHg . Art.

The effect of sodium restriction is more pronounced in elderly and senile patients, in patients with diabetes, MS and CKD. Restricting salt may lead to a reduction in the number of antihypertensive drugs taken and their doses.

1. Patients are recommended to reduce their consumption of alcoholic beverages.
2. Patients are advised to change their diet
3. Patients are recommended to normalize their body weight.
4. Patients are advised to increase physical activity.
5. Patients are advised to quit smoking.

Diagnosis and treatment of secondary forms of arterial hypertension (hypertension)

Secondary (symptomatic) hypertension is a disease in which the cause of increased blood pressure is damage to various organs or systems, and hypertension is only one of the symptoms of the disease. Secondary hypertension is detected in 5-25% of patients with hypertension. To diagnose secondary forms of hypertension, a detailed examination of the patient is fundamentally important, starting from: questioning, examination, laboratory diagnostics, to complex instrumental methods.

Surgery

If drug therapy is ineffective, invasive procedures such as renal denervation and baroreceptor stimulation are recommended.

From this article you will learn how arterial hypertension manifests itself and what drugs are used to treat the disease. The treatment regimen depends on the degree of pressure increase and is selected individually for each patient.

General information and classification

Arterial hypertension is a clinical syndrome characterized by an increase in systolic blood pressure (SBP) over 140 mmHg. and/or diastolic blood pressure (DBP) over 90 mmHg. The syndrome is not equivalent to hypertension, but can occur in secondary forms. The diagnosis of “essential hypertension” or essential hypertension is given to patients who do not have diseases of the internal organs that lead to increased blood pressure. Secondary variants of pathology are found in diseases of the kidneys and endocrine system.

What is AG in the video:

To select antihypertensive therapy, doctors determine the severity of changes in blood pressure and carry out risk stratification in the patient. In clinical practice, the classification of arterial hypertension (AH) is used, presented in Table 1.

Laboratory tests include determination of the level of total cholesterol, low and high density lipoproteins and triglyceride. In the presence of kidney disease, glomerular filtration rate and creatinine clearance are measured. Carrying out a glucose tolerance test allows you to identify glucose imbalances and suspect diabetes mellitus in a patient. In the urine, it examines the amount of protein, glucose and blood elements.

Instrumental methods make it possible to assess the condition of target organs, the functioning of which is disrupted as a result of increased blood pressure. The following diagnostic procedures are used:

electrocardiogram (ECG) to detect left ventricular myocardial hypertrophy;

if pathology is detected on the ECG, the patient undergoes an echocardiogram to assess the condition of the heart chambers and blood flow in them;

Ultrasound with Dopplerography of the brachiocephalic arteries to detect atherosclerotic changes in their walls;

Renal ultrasound is performed for patients who have clinical or biochemical signs of diseases of the urinary system;

examination of the fundus with assessment of the condition of blood vessels;

Daily monitoring of blood pressure levels is carried out for those patients who have signs of arterial hypertension without detecting it when measured in a doctor’s office or at home.

Based on the examination, the doctor formulates a clinical diagnosis and calculates the cardiovascular risk for the patient. These parameters allow you to select an effective treatment regimen for hypertension and measures to prevent complications of the disease.

Purpose of treatment and its purpose

Complex therapy prevents the patient from developing complications from internal organs: heart, brain and kidneys. To achieve this goal, it is necessary to reduce blood pressure levels<140/90 мм.рт.ст., исключить модифицируемые факторы риска и проводить лечение имеющихся сердечно-сосудистых, церебральных и почечных поражений. Treatment of the disease includes the use of antihypertensive and other medications, as well as lifestyle changes.

The use of antihypertensive drugs is indicated for the following groups of patients:

patients with arterial hypertension of 2 and 3 degrees, regardless of the degree of risk;

patients with stage 1 hypertension at high and very high risk of general cardiovascular complications;

patients with stage 1 hypertension who maintain high blood pressure levels after lifestyle changes and exclusion of modifiable risk factors;

patients aged > 80 years.

Patients with arterial hypertension of the 1st degree and with a moderate level of risk need to adhere to lifestyle changes for several months with constant monitoring of blood pressure levels and outpatient visits to the doctor.

Lifestyle change

Clinical recommendations for the treatment of hypertension include lifestyle changes for patients with any stage of hypertension. They lower blood pressure, reduce the patient's need to use antihypertensive drugs and increase their effectiveness, as well as eliminate risk factors for disease progression.

To correct lifestyle, the patient follows the doctor’s recommendations:

in the diet, reduces the consumption of table salt and increases the amount of vegetables, fruits and herbs. It is necessary to reduce the amount of animal fats in the diet;

exclude alcoholic beverages and smoking;

normalizes body weight through nutritional correction and moderate aerobic physical activity: walking, swimming in the pool, cycling.

The effectiveness of lifestyle changes is assessed over a period of 3-4 months. The patient independently keeps a diary of blood pressure, measuring it in the morning and evening every day. Once a week it is necessary to visit your doctor to assess the effectiveness of non-drug treatment and its correction.

Use of Medicines

Five groups of medications are used to treat arterial hypertension:

angiotensin-2 receptor antagonists;

calcium channel blockers;

beta blockers;

diuretic drugs.

Review of the most effective drugs.

These medications have been proven to reduce the risk of developing cardiovascular complications. Before using them, the doctor must exclude the presence of relative and absolute contraindications in the patient.

Table 2. Contraindications to antihypertensive drugs.

Pharmacological group	Absolute contraindications	Relative contraindications
Angiotensin-converting enzyme inhibitors		Women of childbearing age
Angiotensin-2 receptor antagonists	Pregnancy, hyperkalemia, bilateral narrowing of the renal arteries	Women of childbearing age
Beta blockers	Bronchial asthma, atrioventricular block II and III degrees	Athletes and people leading an active lifestyle, COPD, metabolic syndrome, impaired glucose tolerance
Calcium channel blockers	None	Chronic heart failure, tachyarrhythmias
Diuretics	Renal failure, hyperkalemia, gout	None

When choosing a specific treatment regimen, the doctor analyzes the patient’s contraindications, as well as the presence of complications of the disease from internal organs.

Angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) are the main groups of medications for the treatment of primary and symptomatic arterial hypertension. The drugs help control the patient’s blood pressure and reduce the risk of target organ damage. The main protective effect is associated with the prevention of kidney damage. The most commonly prescribed antihypertensive therapy is Enalapril, Lisinopril and Ramipril. The first and third drugs are prodrugs, i.e. have a therapeutic effect in the human body only after chemical modification. This causes a later hypotensive effect compared to Lisinopril.

Beta blockers

Beta blockers block receptors for adrenaline and its analogues located in the heart muscle, blood vessels and bronchi. Different drugs from this pharmacological group have different selectivity, that is, the ability to bind to a specific type of receptor. The higher the degree of selectivity of the drug, the lower the risk of the patient developing side effects - shortness of breath, a feeling of suffocation, etc. Selective beta blockers are used to treat arterial hypertension: Nebivolol, Bisoprolol, Carvedilol. Medicines of this group are recommended for treatment of patients with diagnosed coronary heart disease, as they allow the treatment of both diseases.

Calcium channel blockers

When using medications, a decrease in heart rate and blood pressure levels is observed. The mechanism of action is due to the blocking of calcium channels in the wall of blood vessels and their dilation. Amlodipine is used for basic therapy. The drug is used in combination with drugs from other groups.

Diuretics

Thiazide diuretics are the main group of diuretics for the treatment of arterial hypertension. For antihypertensive therapy, Indapamide and Hydrochlorothiazide are used. Long-term use of thiazide diuretics reduces the number of positive ions in the wall of blood vessels, which ensures their dilation and a decrease in blood pressure. Drugs in this group are not used as monotherapy, but are prescribed with other drugs - angiotensin-converting enzyme inhibitors, calcium channel blockers, etc.

Angiotensin receptor inhibitors

Sartans are a modern group of medications that eliminate the effect of angiotensin on blood vessels. The therapeutic effects are similar to drugs that inhibit angiotensin-converting enzyme. Sartans include Valsartan and Losartan. They are often used in patients with cough that has developed during the use of Enalapril and its analogues.

Other drugs to control blood pressure

In addition to these drugs, other medications are used for antihypertensive therapy: potassium-sparing diuretics (Spironolactone), imidazoline receptor agonists (Moxonidine), direct renin inhibitors (Aliskiren), alpha-blockers (Prazosin). These drugs are used as part of complex treatment in patients who have contraindications to the use of standard approaches. It is not recommended to use them as monotherapy, since the effectiveness of such a prescription is low.

Choice of treatment tactics

In the clinic, a mono- or combined approach can be used to treat arterial hypertension. Monotherapy using one antihypertensive drug can be performed in patients with stage 1 hypertension with a low or moderate risk of developing cardiovascular complications. In all other cases, it is recommended to use combinations of drugs. Monotherapy has a number of advantages at the beginning of treatment: the doctor can easily change the type of drug used or increase its dosage, achieving a good effect. Such changes in treatment also have a negative effect - the patient’s adherence to therapy decreases, which may lead to a decrease in its effectiveness due to refusal to take the medication.

The use of combination therapy has a positive effect for the patient. Prescribing two drugs with a hypotensive effect allows you to reduce the dosage of each of them, which, while maintaining effectiveness, increases the safety of the drugs for the patient. A combination of medications with different mechanisms of action blocks several parts of the increase in blood pressure, ensuring its stable reduction. Modern combination drugs increase a person's adherence to therapy, since several drugs are combined in one tablet. A similar drug is Equator, which contains an angiotensin-converting enzyme inhibitor and a thiazide diuretic.

In the complex treatment of essential and symptomatic hypertension, the following combinations of drugs are used:

angiotensin-converting enzyme inhibitor and diuretic;

diuretic and beta blocker;

diuretic and sartan;

angiotensin-converting enzyme inhibitor and calcium antagonist;

calcium antagonist and diuretic;

alpha blocker and beta blocker.

Only a doctor should select a treatment regimen and dosage of medications. Self-medication for arterial hypertension is unacceptable. The disease can progress rapidly and lead to the development of complications from internal organs.

Prevention

Arterial hypertension requires long-term therapy. The World Health Organization calls on medical professionals and people to pay attention to the possibilities of primary prevention of the disease before the first symptoms appear. It is possible to prevent the development of hypertension in the following ways:

eliminate bad habits - smoking and drinking alcohol;

correction of diet. Fatty foods rich in animal fats and fried foods should be excluded from food. In the diet, increase the share of fresh vegetables, fruits, lean meats, nuts and dairy products;

provide regular physical activity up to 150 minutes per week or more;

If you have diseases of the internal organs, primarily the urinary and endocrine systems, follow the treatment prescribed by your doctor. Kidney disease can cause the development of nephrogenic hypertension, which is difficult to treat;

normalize body weight.

For timely detection of the disease, it is recommended to regularly undergo preventive medical examinations and independently measure blood pressure.

Complications

Chronic high blood pressure changes the wall of the arteries. It becomes dense and fragile, and the lumen of the vessel narrows. Changes can lead to serious complications in patients:

Characterized by a sharp increase in blood pressure, which can cause damage to internal organs

stroke of hemorrhagic or ischemic nature;

coronary heart disease with a high risk of developing myocardial infarction;

degenerative changes in the kidneys and chronic renal failure;

changes in the vessels of the retina with its degeneration and loss of vision.

The use of medications and non-drug therapy allows you to control blood pressure levels and prevent the consequences of hypertension.