The concept of antihypertensive therapy includes a set of pharmacological and non-pharmacological measures aimed at stabilizing blood pressure values and preventing complications of hypertension. This is a combined regimen that includes medications and recommendations for the modification of risk factors, individually selected for the patient. Their implementation ensures the stabilization of pressure indicators, a decrease in the actual frequency of complications or their maximum delay, and an improvement in the patient's quality of life.
Intro
Paradoxical! If everything is fine in words and printed materials of the press, then statistics reveal many problems. Among them are refusal to follow medical recommendations, lack of discipline in the patient, indulgence and inability to fully follow prescriptions. This is partly due to the unjustifiably low level of trust in medical workers, the abundance of mediamisinformation about cardiovascular disease, medicine and beauty. This publication is intended to partially correct this situation, to reveal the concept of antihypertensive therapy for a patient, to characterize pharmacological treatment and approaches to its improvement in different categories of patients.
This voluminous material provides complete information on the treatment of hypertension with pharmacological and non-pharmacological means. Combination therapy with antihypertensive drugs is considered most fully in the context of the initially set goals of treatment. We advise you to carefully and thoughtfully study the article from beginning to end and use it as a material explaining the need for treatment of hypertension and methods of therapy.
Any of the information below is not new to the internist or cardiologist, but will be very helpful to the patient. It will be impossible to draw the right conclusions with a cursory review or a “vertical” reading of the material. Any theses of this publication should not be taken out of context and presented as advice to other patients.
Prescribing drugs or selecting antihypertensive therapy is a difficult job, the success of which depends on a competent professional interpretation of risk factors. This is an individual work of a specialist with each patient, the result of which should be a treatment regimen that avoids high pressure values. It is important that simple, understandable for each patient and universal recommendations for the selectionthere is no antihypertensive treatment.
Goals of antihypertensive therapy
One of the many mistakes patients make is the lack of a solid idea of what antihypertensive therapy is being selected for. Patients refuse to think about why it is necessary to treat hypertension and stabilize blood pressure. And as a result, only a few adequately understand why all this is needed and what awaits them in case of refusal of therapy. So, the first goal, for the sake of which antihypertensive therapy is carried out, is to improve the quality of life. It is achieved through:
- reduce episodes of malaise, headaches, dizziness;
- reducing the number of hypertensive crises with the need to provide emergency care with the involvement of medical workers;
- reduce periods of temporary disability;
- increase exercise tolerance;
- eliminate painful psychological sensation from the presence of symptoms of hypertension, increase comfort through stabilization;
- eliminate or minimize episodes of complicated hypertension crises (nosebleeds, cerebral and myocardial infarction).
The second goal of drug antihypertensive therapy is to increase life expectancy. Although it should be more correctly formulated as the restoration of the former, which took place before the development of the disease, the potential for life expectancy due to:
- decrease in the rate of hypertrophic and dilated transformation of the myocardium;
- reducing the likelihood and actual incidence of atrial fibrillation;
- reducing the likelihood and frequency, reducing the severity or completely preventing the development of chronic kidney disease;
- prevent or delay the severe complications of hypertension (myocardial infarction, cerebral infarction, intracerebral hemorrhage);
- reducing the rate of development of congestive heart failure.
The third goal of treatment is pursued in pregnant women and is associated with a decrease in the total number of complications and abnormalities during gestation during childbirth or in the recovery period. High-quality and sufficient antihypertensive therapy in pregnancy in terms of average blood pressure is a vital necessity for the normal development of the fetus and its birth.
Therapy approaches
Antihypertensive therapy should be carried out systematically and in a balanced way. This means that in the treatment it is necessary to adequately take into account the existing risk factors in a particular patient and the likelihood of developing associated complications. The ability to simultaneously influence the mechanism of the development of hypertension, prevent or reduce the frequency of possible complications, reduce the likelihood of aggravation of the course of hypertension, and improve the patient's he alth formed the basis of modern therapeutic schemes. And in this context, we can consider such a thing as combined antihypertensive therapy. It includes both pharmacological and non-drug directions.
Pharmacological treatment of hypertension is the use of drugs that affect specific biochemical and physical mechanisms of blood pressure formation. Non-drug therapy is a set of organizational measures aimed at eliminating any factors (overweight, smoking, insulin resistance, physical inactivity) that can cause hypertension, aggravate its course or accelerate the development of complications.
Treatment tactics
Depending on the initial pressure figures and the presence of risk factors on a stratification scale, a specific treatment tactic is chosen. It can only consist of non-pharmacological measures if, on the basis of daily monitoring, hypertension of the 1st degree without risk factors is exposed. At this stage of the development of the disease, the main thing for the patient is the systematic control of blood pressure.
Unfortunately, in this publication, it is impossible to briefly, easily and clearly explain to each patient the principles of antihypertensive therapy based on arterial hypertension risk stratification scales. In addition, their evaluation is needed to determine the time of initiation of drug treatment. This is a task for a specially trained and trained employee, while the patient will only need to follow the doctor's recommendations in a disciplined manner.
Transition to medication
In case of inadequate reduction in pressure figures as a result of weight loss, smoking cessation and modification of the diet, antihypertensive drugs are prescribed. Their list willdiscussed below, but it should be understood that drug therapy will never be sufficient if the treatment regimen is not adequately followed and medications are skipped. Also, drug therapy is always prescribed along with non-drug treatments.
It is noteworthy that antihypertensive therapy in elderly patients is always based on drugs. This is explained by the already existing risk factors for coronary heart disease with an inevitable outcome in heart failure. The drugs used for hypertension significantly slow down the rate of development of heart failure, which justifies this approach even from the moment of initial detection of hypertension in a patient over 50.
Priorities in the management of hypertension
Effectiveness of non-drug measures that prevent the development of complications and help control blood pressure in target numbers is very high. Their contribution to the reduction of the average pressure value with adequate disciplined implementation of the recommendations by the patient is 20-40%. However, with hypertension of the 2nd and 3rd degree, pharmacological treatment is more effective, as it allows you to reduce pressure numbers, as they say, here and now.
For this reason, with hypertension of the 1st degree without complications, the patient can be treated without taking drugs. With the 2nd and 3rd degrees of hypertension, antihypertensive drugs used in therapy are simply necessary to maintain working capacity and comfortable life. In this case, priority is given to the appointment of 2, 3 or more antihypertensive drugs from differentpharmacological groups at low doses instead of using one type of drug at high doses. Several drugs used in the same treatment regimen affect the same or more mechanisms for increasing blood pressure. Because of this, drugs potentiate (mutually reinforce) each other's effect, resulting in a stronger effect at low doses.
In the case of monotherapy, one drug, even at high doses, affects only one mechanism of blood pressure formation. Therefore, its effectiveness will always be lower, and the cost will be higher (drugs in medium and high doses always cost 50-80% more). In addition, due to the use of one drug in high doses, the body quickly adapts to the xenobiotic and accelerates its introduction.
With monotherapy, the rate of the so-called addiction of the body to the drug and the "escape" of the effect of therapy is always faster than in the case of prescribing different classes of drugs. Therefore, it often requires correction of antihypertensive therapy with a change in drugs. This creates the prerequisites for the fact that patients form a large list of drugs that, in the case of him, no longer “work”. While they are effective, they just need to be combined properly.
Hypertensive crisis
A hypertensive crisis is an episode of high blood pressure during treatment with the appearance of stereotypical symptoms. Among the symptoms, the most common is a pressing headache, discomfort in the parietal and occipitalareas, flies before the eyes, sometimes dizziness. Less commonly, a hypertensive crisis develops with a complication and requires hospitalization.
It is important that even against the background of effective therapy, when the average blood pressure figures meet the standards, a crisis can (and periodically happens) occur. It appears in two versions: neurohumoral and water-s alt. The first develops quickly, within 1-3 hours after stress or heavy exercise, and the second develops gradually, over 1-3 days with excessive accumulation of fluid in the body.
The crisis is stopped by specific antihypertensive drugs. For example, with a neurohumoral variant of the crisis, it is reasonable to take the drug "Captopril" and "Propranolol" or seek medical help. With a water-s alt crisis, the most appropriate would be to take loop diuretics (Furosemide or Torasemide) along with Captopril.
It is important that antihypertensive therapy in hypertensive crisis depends on the presence of complications. An uncomplicated variant is stopped independently according to the above scheme, and a complicated one requires an ambulance call or a visit to the emergency department of inpatient he althcare facilities. Crises more than once a week indicate the failure of the current antihypertensive regimen, which requires correction after contacting a doctor.
Rare crises that occur with a frequency less than 1 time in 1-2 months do not require correction of the main treatment. Intervention in an effective regimen of combination antihypertensive therapy in elderly patients is carried out as a last resort, only when evidence of an “escape” effect is obtained, with poortolerance or allergic reaction.
Hypertension drug groups
Among antihypertensive drugs, there are a huge number of trade names, which are neither necessary nor possible to list. In the context of this publication, it is appropriate to single out the main classes of drugs and briefly characterize them.
1st group - angiotensin-converting enzyme inhibitors. The ACE inhibitor group is represented by such drugs as Enalapril, Captopril, Lisinopril, Perindopril, Ramipril, Quinapril. These are the main drugs for the treatment of hypertension, with the ability to slow the development of myocardial fibrosis and delay the onset of heart failure, atrial fibrillation, renal failure.
2nd group - angiotensin receptor blockers. The drugs of the group are similar in efficiency to ACE inhibitors, since they exploit the same angiotensinogen mechanism. However, ARBs are not enzyme blockers, but angiotensin receptor inactivators. In terms of efficiency, they are somewhat inferior to ACE inhibitors, but also slow down the development of CHF and CRF. This group includes the following medicines: Losartan, Valsartan, Candesartan, Telmisartan.
3rd group - diuretics (loop and thiazide). "Hypothiazid", "Indapofon" and "Chlortalidone" are relatively weak thiazide diuretics, convenient for continuous use. Loop diuretics "Furosemide" and "Torasemide" are well suited for stopping crises, although they can also be prescribed on an ongoing basis, especially with already developed congestive CHF. Diureticsof particular value is their ability to increase the effectiveness of ARBs and ACE inhibitors. Antihypertensive therapy during pregnancy involves the use of diuretics as a last resort, when other drugs are ineffective, due to their ability to reduce placental blood flow, while in other patients it is the main (and almost always mandatory) drug for treating hypertension.
4th group - adrenergic blockers: "Metoprolol", "Bisoprolol", "Carvedilol", "Propranolol". The latter drug is suitable for stopping crises because of the relatively fast action and effect on alpha receptors. The rest of the drugs on this list help control blood pressure, but are not the main ones in the antihypertensive regimen. Doctors value their proven ability to increase the life expectancy of patients with heart failure when taken with ACE inhibitors and diuretics.
5th group - calcium channel blockers: Amlodipine, Lercanidipine, Nifedipine, Diltiazem. This group of drugs is widely used in the treatment of hypertension due to the possibility of taking it by pregnant patients. Amlodipine has a beneficial effect of nephroprotection, which, together with the use of ACE inhibitors (or ARBs) and diuretics, slows down the development of chronic renal failure in malignant hypertension in non-pregnant patients.
6th group - other medicines. Here it is necessary to indicate heterogeneous drugs that have found application as antihypertensive drugs and have heterogeneous mechanisms of action. These are Moxonidine, Clonidine, Urapidil, Methyldopa and others. A complete list of medicines is always present by a doctor and notrequires memorization. It is much more profitable if each patient remembers well his antihypertensive regimen and those drugs that were successfully or unsuccessfully used earlier.
Antihypertensive therapy in pregnancy
During pregnancy, the most commonly prescribed drugs are Methyldopa (category B), Amlodipine (category C), Nifedipine (category C), Pindolol (category B), Diltiazem (category C)). At the same time, an independent choice of drugs by a pregnant woman is unacceptable because of the need for primary diagnosis of increased blood pressure. Diagnosis is required to exclude preeclampsia and eclampsia - dangerous pathologies of pregnancy. The choice of treatment will be carried out by the attending physician, and any increase in blood pressure in a pregnant woman that was not previously observed (before pregnancy) should be carefully studied.
Hypotensive therapy during lactation is subject to strict rules: in the first case, if the blood pressure is not higher than 150/95, breastfeeding can be continued without taking antihypertensive drugs. In the second case, with blood pressure in the range of 150/95-179/109, low-dose use of antihypertensive drugs is practiced (the dose is prescribed by a doctor and controlled under the supervision of medical staff) with continued breastfeeding.
The third type of antihypertensive therapy in pregnant and lactating women is the treatment of hypertension, including combined, with the achievement of target blood pressure figures. This requires avoiding breastfeeding and continuous use of essential drugs: ACE inhibitors or ARBs with diuretics, calcium channel blockers, andbeta-blockers, if required for successful treatment.
Antihypertensive therapy for chronic renal failure
Treatment of hypertension in chronic renal failure requires dispensary medical supervision and careful attitude to doses. The priority drug groups are ARBs with loop diuretics, calcium channel blockers, and beta-blockers. Combination therapy of 4-6 drugs at high doses is often prescribed. Due to frequent crises in chronic renal failure, the patient may be prescribed "Clonidine" or "Moxonidine" for continuous use. It is recommended to stop hypertensive crises in patients with CRF with injectable "Clonidine" or "Urapidil" with a loop diuretic "Furosemide".
Hypertension and glaucoma
Patients with diabetes mellitus and chronic renal failure often have damage to the organ of vision associated with both retinal microangiopathy and hypertonic lesion. An increase in IOP to 28 with or without antihypertensive therapy indicates a tendency to develop glaucoma. This disease is not associated with arterial hypertension and damage to the retina, it is damage to the optic nerve as a result of an increase in intraocular pressure.
The value of 28 mmHg is considered borderline and characterizes only the tendency to develop glaucoma. Values above 30-33 mmHg are a clear sign of glaucoma, which, together with diabetes, chronic renal failure and hypertension, can accelerate the loss of vision in a patient. It should be treated along with the main pathologies of the cardiovascular and urinary systems.
