Treatment of arterial hypertension

Author Ольга Кияница

2018-12-02

Arterial hypertension may have varying degrees of severity, and in each case the most appropriate treatment is selected. Sometimes it is possible to confine oneself to the correction of a habitual way of life; other patients need long-term or lifelong drug therapy.

Arterial hypertension (AH, outdated hypertension) is a cardiovascular disease that is characterized by an increase in blood pressure followed by the risk of developing other pathologies (myocardial infarction, stroke, vascular aneurysm).

According to statistics, almost 50% of people over 60 years of age determine hypertension, so about 20% of the world's population can be considered hypertensive.

For the diagnosis of arterial hypertension, first of all, an elementary pressure measurement using a tonometer and a stethoscope is used. If necessary, conduct laboratory tests and echocardiography. If the diagnosis of hypertension is confirmed, then treatment is surely prescribed to prevent the development of serious complications.

Video: Treatment of hypertension

General recommendations for the treatment of arterial hypertension

Blood pressure (BP) in normal should not exceed 130 mm Hg. st. (upper threshold) and 85 mm Hg. st. (lower threshold).Otherwise, high or normal blood pressure, mild hypertension, moderate or severe hypertension can be determined. To stop the progression of the disease or prevent hypertensive crises, first of all, general recommendations should be followed:

  • weight loss;
  • alcohol restriction;
  • normalization of the diet;
  • stress management;
  • correction of physical activity;
  • reduction of sodium intake, etc.

Weight loss

Before starting to use the weight loss program, height, weight and waist circumference, as well as body mass index (BMI) are determined.

Today there is evidence of a positive connection between obesity and high blood pressure. Although BMI is not an indication of directly measuring body fat, it is still most often used to determine the degree of obesity, because it is simple to calculate.

In the Framingham study, for every 4.5 kg of weight gain, an increase in systolic blood pressure of 4 mm Hg was observed. Art. (in men and women). In addition, blood pressure potentially decreased by 1.6 mm Hg. / 1.1 mmHg Art.when the weight per 1 kg decreases.

The high content of abdominal fat (AJ, fat deposits in the abdomen) contributes to the development of hypertension even more. The standard method for determining the AF is that the centimeter for measurement is horizontal, halfway between the iliac crests and the lower part of the chest.

It is recommended to maintain a healthy body weight within:

  1. The body mass index is from 18.5 to 24.9 kg / m2.
  2. Waist circumference of not more than 102 cm for men and 88 cm for women.

Such indicators should be followed by all persons who do not suffer from hypertension, as well as when it is necessary to prevent hypertension or reduce blood pressure. Overweight people with hypertension should take care of weight loss.

For overweight patients, the effectiveness of weight loss for reducing blood pressure is similar to that of a one-time antihypertensive therapy.

Weight loss strategies should be based on a multidisciplinary approach, which includes proper diet, increased physical activity and correction of behavioral habits.

Alcohol consumption

To prevent hypertension and reduce blood pressure, it is necessary to limit the consumption of alcoholic beverages, that is, drink no more than 2 drinks per day. At the same time, men should not exceed the rate of 14 standard drinks per week, and women - 9 standard drinks per week.

Note: one standard drink is considered equivalent to 13.6 g or 17.2 ml of ethanol or approximately 44 ml of 40% alcohol, 355 ml of 5% beer or 148 ml of 12% wine.

Some randomized controlled trials have shown that restricting alcohol intake can lead to normalization of blood pressure; however, statistical significance in other studies, possibly due to low commitment to alcohol reduction interventions, does not confirm this. In general, the data do not provide convincing evidence, but are consistent with the findings that the consumption of heavy alcoholic beverages leads to an increase in blood pressure.

Diet

People with hypertension or normotension, but with an increased risk of developing hypertension, it is recommended to use in the diet:

  • fruits;
  • vegetables;
  • low-fat dairy products;
  • fiber-rich whole grain foods;
  • proteins from plant sources that do not turn into saturated fat and cholesterol.

More carefully diet food is painted in the DASH-diet.

It is important to note that among patients not suffering from hypertension, the use of an antihypertensive diet reduced blood pressure by 3.5 / 2.1 mmHg. Art., whereas in the presence of hypertension, the DASH diet reduced blood pressure by 11.4 / 5.5 mm Hg. Art.

Stress management

When blood pressure rises against the background of stress, emotional state management is most often considered as the primary stage in the treatment of hypertension. In particular, individualized cognitive-behavioral interventions are more effective when using relaxation techniques.

Evidence over the past few decades suggests that psychosocial factors associated with an emotional state, such as depression, behavioral dispositions in the form of hostility and psychosocial stress, can directly affect both physiological function and health outcomes. .

Scientific reviews indicate that stress associated with depression, social exclusion and lack of high-quality social support increases the risk of developing coronary heart disease. In such cases, stress becomes similar to common risk factors, such as smoking, dyslipidemia, and hypertension.

Current evidence suggests a link between psychosocial factors and atherosclerosis; however, the specific nature of the association is unknown. It is still unclear what the role of stress management is with respect to the long-term results associated with the incidence of arterial hypertension. However, although there is no evidence that stress management prevents hypertension, there is some evidence to lower blood pressure when using psychotherapy in the presence of hypertension.

Most often, centers offer transcendental meditation or relaxation therapy. Also, multicomponent, individualized cognitive behavioral interventions reduce blood pressure to a large extent and over a long period of time.

It should be noted that with individualized management of cognitive stress, blood pressure decreases by an average of 15.2 / 9.2 mm Hg. Art. The key to this approach is the adaptation of the intervention to the needs of the patient.

The strategies used in individualized cognitive behavioral stress therapy are most often based on:

  • raising awareness of stress reactions;
  • revaluation of negative life events;
  • learning communication skills (for example, marriage and self-affirmation);
  • developing problem solving skills;
  • managing negative emotions (such as anger and anxiety);

Additionally, methods for reducing sympathetic arousal (for example, relaxation exercises) can be used.

Exercise correction

To reduce the likelihood of developing hypertension or to reduce blood pressure, it is necessary to perform dynamic exercises of moderate intensity (for example, walking, jogging, cycling or swimming) for 30-60 minutes 4-7 days a week in addition to normal daily work. More intense exercise is no longer beneficial.

In the presence of high-normal blood pressure or hypertension, 1 degree, the use of endurance exercises or weight exercises (for example, free weight lifting, fixed weight lifting) does not adversely affect your well-being.

At the risk of an acute increase in blood pressure and the potential use of Valsalva maneuver during weight training, there is a fear that this form of exercise may contribute to an increase in blood pressure. In extreme cases, this load leads to an increased risk of hemorrhagic stroke or subarachnoid hemorrhage.

Video: Hypertension. How to treat? There are two simple exercises of Dr. Bubnovsky.

Other recommendations

  • Sodium consumption

To prevent hypertension or reduce blood pressure in developing hypertension, you should consider reducing sodium intake to 2,000 mg per day. This amount equates to 5 g of salt or 87 mmol of sodium.

In 36 randomized controlled trials involving 5508 people, from which 1478 people had hypertension, a decrease in sodium intake resulted in a decrease in blood pressure by an average of 3.39 mm Hg. st. all examined and at 4.06 mm Hg. st. in the subgroup with hypertension. In this case, the simultaneous use of antihypertensive drugs, basically, did not reduce the negative impact of sodium consumption.

  • Calcium and magnesium intake

Use as an additive of calcium and magnesium is not recommended for the prevention or treatment of hypertension.

Proper intake of potassium, calcium and magnesium is an important component of the DASH diet. Trace elements soften sensitivity to salt and seem to have a wide range of benefits, in addition to reducing blood pressure. In particular, insulin resistance is reduced and lipid metabolism is improved.

Evidence from randomized controlled trials show that increasing intake or adding magnesium or calcium to the diet is not associated with the prevention of hypertension, as well as an effective reduction in high blood pressure. Therefore, in the presence of hypertension, it is important to adhere to an adequate intake of calcium and magnesium cations, both in the form of dietary supplements and as food additives.

  • Potassium intake

In the absence of the risk of hyperkalemia, calorie intake with food should be increased, as this allows to reduce blood pressure.

The magnitude of the expected reduction in blood pressure appears to be the same regardless of whether potassium intervention is carried out through dietary changes or prescribed supplements. However, if possible, dietary modification is still desirable as a preferred method of increasing potassium intake due to the additional nutritional benefits of whole foods compared to prescribed supplements.

If necessary, a physician with hypertension may recommend eating foods with a higher potassium content (for example, fresh fruits, vegetables, and legumes). In general, potash supplements appear to be largely safe without an increase in reported side effects. However, potassium supplements should be cautious for individuals with a higher risk of developing hyperkalemia, for example:

  1. When using inhibitors of the renin-angiotensin-aldosterone system.
  2. Upon receipt of other drugs that may cause hyperkalemia (for example, trimethoprim and sulfamethoxazole, amiloride or triamterene).
  3. In the presence of chronic kidney disease, when the glomerular filtration rate is less than 60 ml / min.
  4. In the presence of the original serum potassium more than 4.5 mmol / l.

General principles of drug treatment of arterial hypertension

Initially, patients with hypertension are prescribed either monotherapy or a combination of drugs.

Indications for treatment of arterial hypertension: an increase in systolic blood pressure up to 140 mm Hg. and higher, and diastolic blood pressure - up to 90 mm Hg. and higher.

For monotherapy, the following treatment options are most often used:

  1. Thiazide or thiazide-like diuretic, it is preferable to use long-acting drugs.
  2. Beta-blocker - most often prescribed to patients younger than 60 years.
  3. Angiotensin-converting enzyme inhibitor (ACE inhibitor).
  4. Angiotensin enzyme blocker.
  5. Long-acting calcium channel blocker.

The combination of drugs for the treatment of high blood pressure is mainly represented by the following schemes:

  • an ACE inhibitor + calcium channel blocker (class A);
  • angiotensin receptor blocker + calcium channel blocker ((class B);
  • ACE inhibitor or angiotensin receptor blocker + diuretic (class B).

It is important to know that when using thiazide or thiazide-like diuretics, hypokalemia may occur, which should be avoided if possible.

Additional antihypertensive drugs can be used if the level of target blood pressure is not achieved with monotherapy with a standard dose. In particular, drug combinations such as an ACE inhibitor with a beta blocker or an angiotensin receptor blocker with thiazide / thiazide-like drug are used. If this BP is still not controlled by a combination of two or more first-line drugs, or there are side effects, other antihypertensive drugs may be added.

Recommendations for patients with isolated systolic hypertension

  1. Initially, it is desirable to use a single drug in treatment, for example, a thiazide or a thiazide-like diuretic, a long-acting calcium channel blocker, or a thiazide receptor blocker. If there are side effects, the doctor can replace it with another drug from this group.
  2. Additional antihypertensive drugs should be used if the level of target blood pressure is not achieved with a standard dose monotherapy. Suitable drugs can be selected from first-line antihypertensive agents.
  3. If BP is still not controlled by a combination of two or more first-line drugs, or if there are side effects, other classes of drugs (such as α-blockers, ACE inhibitors, centrally acting agents or non-dihydropyridine calcium channel blockers) can be added. case they are replaced.

It is important to know that:

  • α-blockers are not recommended as first-line agents for uncomplicated isolated systolic hypertension;
  • β-blockers are not recommended as first-line therapy for isolated systolic hypertension in patients over the age of 60 years.

However, drugs from both groups can be used in the presence of comorbidities or as a combination therapy.

Treatment of hypertension in combination with other diseases

Hypertension in association with CHD

When combined with arterial hypertension and coronary heart disease (CHD), there are certain nuances in the use of drugs. In such cases, treatment is carried out taking into account the following points:

  1. An ACE inhibitor or an angiotensin receptor blocker is recommended for most patients with hypertensive disease and IHD.
  2. In the presence of hypertension and CHD, but without concomitant systolic heart failure, the combination of an ACE inhibitor and an ATP blocker is not recommended.
  3. Patients with a high risk of hypertension, when using combination therapy, the choice is carried out taking into account the individual characteristics of the patient. In particular, a combination of an ACE inhibitor and a dihydropyridine calcium channel blocker can be used. In extreme cases, it is an ACE inhibitor with a thiazide or a thiazide-like diuretic.
  4. If the patient has stable angina, but without previous heart failure, myocardial infarction or coronary artery bypass surgery, either a β-blocker or calcium channel blocker is used, which can be used as initial therapy.
  5. When systolic blood pressure is reduced to the target level, extreme caution should be exercised in patients with established coronary artery disease (especially in the presence of systolic hypertension), especially if the diastolic blood pressure is less than 60 mm Hg. In such cases, the increased risk of exacerbation of myocardial ischemia, especially in the presence of left ventricular hypertrophy.

It is important to note that short-acting nifedipine, as a rule, is not used for arterial hypertension in combination with IHD.

Current guidelines for patients with hypertension who have had a recent myocardial infarction (MI):

  1. Initially, therapy most often includes a beta-blocker and an ACE inhibitor.
  2. Angiotensin receptor blocker can be used if an ACE inhibitor intolerance is observed or a patient has left ventricular systolic dysfunction.
  3. Calcium channel blockers can be used after myocardial infarction, when beta-blockers are contraindicated or ineffective.Nedigidropiridinovy ​​BPC, as a rule, are not used for heart failure.

Additionally, it is important to adhere to diet and reduce the impact of modified risk factors.

Hypertension in association with diabetes

When combined with arterial hypertension and diabetes mellitus, treatment is mainly carried out in order to achieve systolic blood pressure within 130 mm Hg. st. and diastolic blood pressure - 80 mm Hg. st.

If you have other cardiovascular or kidney diseases, including microalbuminuria or cardiovascular risk factors, an ACE inhibitor or angiotensin receptor blocker may be recommended as initial therapy.

In all other cases, the treatment of the association of diabetes and hypertension is carried out using ACE inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers and thiazide or thiazide-like diuretic.

If target blood pressure levels are not achieved with a standard dose monotherapy, additional antihypertensive drugs may be used. When considering combination therapy with an ACE inhibitor, a combination of drugs from this group with a thiazide or a thiazide-like diuretic is preferable.

Hypertension in association with stroke

Arterial hypertension can develop both before and after a stroke. In each case, a specific treatment is carried out. An increase in blood pressure in acute ischemic stroke (onset of the disease up to 72 hours) can be stopped as follows:

  1. Regular treatment is not recommended if hypertension with ischemic stroke is determined and thrombolytic therapy is not indicated. An extreme increase in blood pressure (for example, systolic blood pressure more than 220 mmHg or diastolic blood pressure more than 120 mmHg) can be eliminated to reduce blood pressure by about 15%, but not more than 25% during the first 24 hours with a gradual decrease after the acute period.
  2. It is important to avoid an excessive decrease in blood pressure, because it may aggravate existing ischemia or cause a repeated attack, especially in conditions of intracranial or extracranial arterial occlusion. Therefore, pharmacological agents and the route of their administration is selected in such a way as to avoid a sharp decrease in blood pressure.
  3. If it is possible to use thrombolytic therapy, ischemic stroke in combination with hypertension, when a very high blood pressure value is detected (more than 185/110 mmHg), is treated simultaneously with thrombolysis. This reduces the risk of hemorrhagic transformation of the affected area of ​​the brain. Blood pressure should be reduced to the level of 185/110 mm Hg. st. during therapy and below 180/105 mm Hg. st. over the next 24 hours.

After an acute period of ischemic stroke, the treatment focuses on the following points.

  1. Much attention is paid to the initiation of antihypertensive therapy after
    acute phase of stroke or transient ischemic attack.
  2. After the acute phase of stroke, treatment is recommended with a decrease in blood pressure to a target level of less than 140/90 mm Hg. st.
  3. Preferred is treatment with an ACE inhibitor and a thiazide or a thiazide-like diuretic combination.
  4. For patients with stroke, the combination of an ACE inhibitor and angiotensin receptor blockers is not recommended.

The tactics of treatment for a combination of arterial hypertension with hemorrhagic stroke (up to 72 hours) is to avoid a decrease in systolic blood pressure of less than 140 mm Hg. st. due to the lack of positive effects (with a relative target of less than 180 mm Hg).

Hypertension in association with heart failure

In the presence of systolic dysfunction (ejection fraction less than 40%), initial therapy consists of using an ACE inhibitor and a β-blocker. Aldosterone antagonists (mineralocorticoid antagonists) may be added to patients with recent cardiovascular hospitalization, for example, for acute myocardial infarction.

Careful monitoring of hyperkalemia is recommended when an aldosterone antagonist is added to an ACE inhibitor or an angiotensin receptor blocker. Other diuretics are used, if necessary, as an additional therapy. In addition to proper blood pressure control, doses of ACE inhibitors or ATP blockers are used such that are considered effective and not conducive to the appearance of adverse effects.

Of the other key points:

  1. Angiotensin receptor blockers are recommended in cases where ACE inhibitors are not tolerated.
  2. The combination of hydralazine and isosorbide dinitrate is used when ACE inhibitors and ATP blockers are contraindicated or not tolerated.
  3. Hypertension, in which BP is not controlled, ATP blockers can be added to an ACE inhibitor and other antihypertensive drugs. Careful monitoring should be used if an ACE inhibitor and an ATP blocker are combined due to potential side effects, such as hypotension, hyperkalemia, and impaired kidney function. Additional treatments may also include the use of dihydropyridine calcium channel blockers.
  4. The combination of angiotensin receptor and neprilysin inhibitors can be used instead of an ACE inhibitor or ATP blocker in patients with heart failure and cardiac output of less than 40%, who have symptoms that are determined despite treatment with an appropriate dose of supportive drugs (usually a beta blocker, an ACE inhibitor or ATP blocker, as well as, if necessary, mineralocorticoid antagonist).

In an acceptable condition, a patient with an associative form of hypertension should determine serum potassium less than 5.2 mmol / l, glomerular filtration is greater than or equal to 30 ml / min /. Also, careful monitoring of serum potassium and creatinine is performed.

Hypertension in association with left ventricular hypertrophy

Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to reduce the incidence of subsequent cardiovascular complications.

The presence of left ventricular hypertrophy may influence the choice of initial therapy. First of all, drug therapy based on ACE inhibitors, ATP blockers, long-acting QA blockers or thiazide / thiazide-like diuretics is most often used. It should not be used direct arterial vasodilators, such as hydralazine or minoxidil.

Conclusion

Treatment of hypertension should begin at the beginning of the development of the disease. First of all, the daily lifestyle is adjusted, including nutrition, physical activity, the level of stress exposure, and bad habits. If necessary, add medication therapy. Especially careful should be selected treatment in the presence of concomitant (or primary) disease by type of diabetes, coronary artery disease, right ventricular hypertrophy, etc. In all cases, the attending physician conducts the required research and selection of treatment tactics.

Video: Hypertension - how easy it is to treat without pills. High blood pressure - which treatment is better


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