In significant numbers cases arterial hypertension preceded by the so-called “borderline arterial hypertension” (PAH), although not everyone causes the development of hypertension.
Diagnosis borderline arterial hypertension is established when the systolic level blood pressure(BP) does not exceed 150 mm Hg. Art. diastolic - 94 mm Hg. Art. and with repeated measurements over a period of 2-3 weeks without use antihypertensive therapy are identified and normal numbers HELL.
When diagnosing essential arterial hypertension and an essential step is differentiation from secondary hypertension: renal, endocrine, cerebral origin. AH is established in the absence of these forms.
According to WHO classification stages of arterial hypertension are distinguished. The first stage is understood as an increase in blood pressure as such. The second stage is characterized not only by an increase in blood pressure, but also by damage to target organs (the presence of left ventricular hypertrophy, changes in the vessels of the fundus, kidneys). In the third stage, arteriolosclerosis additionally joins various organs. In addition, arterial hypertension is divided according to the level of blood pressure: when the systolic blood pressure is not higher than 179 mm Hg. Art. and diastolic 105 mm Hg. Art. mild hypertension is diagnosed; with systolic blood pressure 180-499 mm Hg. Art. and diastolic 106-114 mm Hg, st. - moderate hypertension; with systolic blood pressure over 200 mm Hg. Art. and diastolic more than 115 mm Hg. Art. - high hypertension, with a systolic blood pressure value of more than 160 mm Hg. Art. and diastolic less than 90 mm Hg. Art. Isolated systolic hypertension is diagnosed.
WHO classification based on blood pressure levels has become widespread in Europe and the USA. It is taking into account the level of diastolic blood pressure that most randomized studies have been conducted. But epidemiological work in recent years has shown the importance of the value and level of systolic blood pressure. With its high numbers, the risk of cardiovascular complications in patients with hypertension is as great as with high diastolic blood pressure. It should be noted that the term “mild” hypertension does not at all correspond to the prognostic value of this condition. The share of mild hypertension is 70% among all forms of arterial essential hypertension. But it is mild hypertension that affects more than 60% of patients with cerebrovascular accidents (Arabidze G. G. 1995].
Arterial hypertension develops slowly, often over 10 years. In a small proportion of patients with hypertension, a transition to a malignant form is possible when fibrinous-necrotic changes develop in the arterioles. Heart and kidney failure develop, blindness and severe early disability occur. Life expectancy for this form is less than 5 years. Malignant hypertension, apparently, can also be the result of primary vasculitis.
Despite the predominance of complications in the late stage, even the presence of mild and moderate arterial hypertension. according to numerous long-term cooperative studies, it increases the incidence of major complications and atherosclerosis several times compared to normotension. This implies the need to treat even the mildest forms of hypertension.
New approaches to the classification and treatment of arterial hypertension. 1999 World Health Organization and International Society of Hypertension guidelines.
B.A.Sidorenko, D.V.Preobrazhensky, M.K.Peresypko
Medical Center of the Administration of the President of the Russian Federation, Moscow
Arterial hypertension (AH) is the most common cardiovascular syndrome in many countries of the world. For example, in the USA, high blood pressure (BP) is found in 20-40% of the adult population, and in age groups over 65 years of age, hypertension occurs in 50% of the white and 70% of the black races. More than 90-95% of all cases of hypertension are hypertension. In other patients, a thorough clinical and instrumental examination can diagnose a variety of secondary (symptomatic) hypertension. It should be taken into account that in 2/3 of cases, secondary hypertension is caused by damage to the kidney parenchyma (diffuse glomerulonephritis, diabetic nephropathy, polycystic kidney disease, etc.), and therefore is potentially incurable. Treatment of renal hypertension is generally no different from therapy hypertension.
Consequently, in the vast majority of patients with hypertension, long-term drug therapy is carried out regardless of whether the exact cause of high blood pressure is known or not.
The long-term prognosis in patients with hypertension depends on three factors: 1) the degree of increase in blood pressure, 2) damage to target organs and 3) concomitant diseases. These factors must be reflected in the diagnosis of a patient with hypertension.
Since 1959, experts from the World Health Organization (WHO) have periodically published recommendations for the diagnosis, classification and treatment of hypertension based on the results of epidemiological and clinical trials. Since 1993, such recommendations have been prepared by WHO experts together with the International Society of Hypertension (ISH). From September 29 to October 1, 1998, the 7th meeting of WHO and MTF experts took place in the Japanese city of Fukuoka, at which new recommendations for the treatment of hypertension were approved. These recommendations were published in February 1999. Therefore, in the literature, new recommendations for the treatment of hypertension are usually dated back to 1999 - 1999 WHO-ISH guidelines for the management of hypertension (recommendations for the treatment of hypertension WHO-IOG 1999).
In the 1999 WHO-IOG recommendations, hypertension is defined as a systolic blood pressure level of 140 mmHg. Art. or more, and (or) a diastolic blood pressure level equal to 90 mm Hg. Art. or more, in people who are not receiving antihypertensive drugs. Given the significant spontaneous fluctuations in blood pressure, the diagnosis of hypertension should be based on the results of repeated blood pressure measurements during several visits to the doctor.
WHO-ITF experts proposed new approaches to the classification of hypertension. The new classification proposes to abandon the use of the terms “mild”, “moderate” and “severe” forms of hypertension, which were used, for example, in the 1993 WHO-IOG recommendations. To characterize the degree of increase in blood pressure in patients with hypertension, it is now recommended to use the following terms: as grade 1, grade 2 and grade 3 disease. It should be noted that the 1999 classification tightened the criteria for distinguishing between different degrees of severity of hypertension (Table 1).
Table 1. Comparison of criteria for the severity of hypertension in the classifications of WHO and MTF experts in 1993 (1996) and 1999.
Classification 1993(1996)
Hypertension. Classification of hypertension.
Diagnosis of hypertension(essential, primary arterial hypertension) is established by excluding secondary (symptomatic) arterial hypertension. The definition of “essential” means that persistently elevated blood pressure in hypertension is the essence (main content) of this arterial hypertension. No changes in other organs that could lead to arterial hypertension are found during routine examination.
Frequency of essential arterial hypertension accounts for 95% of all arterial hypertension (with a thorough examination of patients in specialized hospitals, this value decreases to 75%).
Genetic aspects.
- Family history. Allows you to identify hereditary predisposition to hypertension of a polygenic nature.
— There are many genetically determined disorders of the structure and function of cell membranes of both excitable and non-excitable types in relation to the transport of Na+ and Ca2+.
Etiology of hypertension.
— The main cause of hypertension: repeated, usually prolonged, psycho-emotional stress. The stress reaction is of a pronounced negative emotional nature.
— The main risk factors for hypertension (conditions contributing to the development of hypertension) are presented in the figure.
Factors involved in the development of hypertension
Excess Na+ causes (among other things) two important effects:
— Increased transport of fluid into cells and their swelling. Swelling of the cells of the walls of blood vessels leads to their thickening, narrowing of their lumen, increased vascular rigidity and a decrease in their ability to vasodilate.
— Increased sensitivity of myocytes of the walls of blood vessels and the heart to vasoconstrictor factors.
— Disorders of the functions of membrane receptors that perceive neurotransmitters and other biologically active substances that regulate blood pressure. This creates a condition for the dominance of the effects of hypertensive factors.
— Disturbances in the expression of genes that control the synthesis of vasodilatory agents (nitric oxide, prostacyclin, PgE) by endothelial cells.
Environmental factors. Highest value have occupational hazards (for example, constant noise, the need for attention); living conditions (including utilities); intoxication (especially alcohol, nicotine, drugs); brain injuries (bruises, concussions, electrical trauma, etc.).
Individual characteristics of the body.
- Age. With age (especially after 40 years), hypertensive reactions mediated by the diencephalic-hypothalamic region of the brain (they are involved in the regulation of blood pressure) to various exo- and endogenous influences dominate.
- Increased body weight, high serum cholesterol, excess renin production.
— Features of the CVS reaction to stimuli. They consist in the dominance of hypertensive reactions to a variety of influences. Even minor emotional (especially negative) influences, as well as factors external environment lead to a significant increase in blood pressure.
Classification of hypertension
In Russia, a classification of hypertension has been adopted (WHO classification, 1978), presented in the table
Table. Classification of hypertension
Stage I of hypertension - increased blood pressure more than 160/95 mm Hg. without organic changes in the cardiovascular system
Stage II of hypertension - increased blood pressure more than 160/95 mm Hg. in combination with changes in target organs (heart, kidneys, brain, fundus vessels) caused by arterial hypertension, but without disruption of their functions
Stage III of hypertension - arterial hypertension, combined with damage to target organs (heart, kidneys, brain, fundus) with impairment of their functions
Forms of essential arterial hypertension.
- Borderline. A type of essential arterial hypertension observed in young and middle-aged people, characterized by fluctuations in blood pressure from normal to 140/90-159/94 mm Hg. Normalization of blood pressure occurs spontaneously. There are no signs of target organ damage typical for essential arterial hypertension. Borderline hypertension occurs in approximately 20-25% of individuals; In 20-25% of them, essential arterial hypertension then develops; in 30%, borderline arterial hypertension persists for many years or throughout life; in the rest, blood pressure normalizes over time.
- Hyperadrenergic. It is characterized by sinus tachycardia, unstable blood pressure with a predominance of the systolic component, sweating, facial flushing, anxiety, and throbbing headaches. It appears in the initial period of the disease (in 15% of patients it persists in the future).
— Hyperhydration (sodium-, volume-dependent). Manifested by swelling of the face and paraorbital areas; fluctuations in diuresis with transient oliguria; when using sympatholytics - sodium and water retention; pale skin; constant bursting headaches.
- Malignant. A rapidly progressing disease with an increase in blood pressure to very high values with visual impairment, the development of encephalopathy, pulmonary edema, and renal failure. Malignant essential arterial hypertension often develops with symptomatic arterial hypertension.
Today, a lot is written and talked about hypertension and its impact on a person’s quality of life. This chronic disease is really worth learning everything that modern medicine knows about it, because according to some estimates, about 40% of the adult population of the planet suffers from it.
The greatest concern is the fact that in recent years there has been a persistent trend toward “rejuvenation” of this disease. Exacerbations of hypertension in the form of hypertensive crises today occur in 40-year-old and even 30-year-old people. Because the problem affects almost everyone age categories For adults, awareness of the pathology called hypertension seems relevant.
The term “hypertension” in everyday life is replaced by another concept – arterial hypertension (AH), but they are not entirely equivalent. Although both mean pathological conditions, characterized by a rise in blood pressure (BP) above 140 mm systolic (SBP) and above 90 mm diastolic (DBP).
But in medical sources, hypertension is defined as hypertension, not provoked by somatic diseases or other obvious reasons causing symptomatic hypertension.
Therefore, when asked what hypertension is and what it means, one should answer - it is primary, or (of uncertain etiology) arterial. This term has found widespread use in European and American medical circles, and the prevalence of the syndrome exceeds 90% of all hypertension diagnoses. For all other forms and general definition syndrome, it is more correct to use the term arterial hypertension.
What can cause development in a person?
Despite the uncertainty of the pathogenesis (causes and mechanisms of origin) of hypertension, several provoking factors and aspects of its potentiation are known.
Risk factors
Normal blood pressure in a healthy vascular system is maintained through the interaction of complex vasoconstrictor and vasodilator mechanisms.
Hypertension is provoked by abnormal activity of vasoconstrictor factors or insufficient activity of vasodilator systems due to a violation of their mutually compensatory functioning.
The triggering aspects of hypertension are considered in two categories:
- neurogenic - caused by a direct effect on the tone of arterioles through sympathetic division nervous system;
- humoral (hormonal) – associated with the intense production of substances (renin, norepinephrine, adrenal hormones) that have vasopressor (vasoconstrictor) properties.
Why exactly the blood pressure regulation fails, resulting in hypertension, has not yet been established. But cardiologists name risk factors for the development of hypertension, identified in the process of many years of research:
- genetic predisposition to heart and vascular diseases;
- congenital pathology of cell membranes;
- unhealthy addictions - smoking, alcoholism;
- neuropsychic overload;
- low physical activity;
- excessive presence of salt in the menu;
- increased waist circumference, indicating metabolic disorders;
- high body mass index (BMI) > 30;
- high values of plasma cholesterol (more than 6.5 mmol/l in total).
The list is not a complete list of everything that can cause hypertension in humans. These are just the main causes of the pathology.
A threatening consequence of hypertension is a high probability of damage to target organs (TOM), which is why such varieties arise as hypertensive heart disease, which affects this organ, renal hypertension and others.
Classification tables by stages and degrees
Because for various forms During the course of hypertension, various clinical recommendations are provided for the choice of therapeutic regimen; the disease is classified according to stages and degrees of severity. Degrees are determined by blood pressure numbers, and stages by the scale of organic damage.
An experimentally developed classification of hypertension by stages and degrees is presented in tables.
Table 1.Classification of hypertension by degree.
The severity of hypertension is classified according to a higher index, for example, if SBP is less than 180 and DBP is more than 110 mmHg, this is defined as stage 3 hypertension.
Table 2.Classification of hypertension by stages.
| Stages of development of headache | Determining factors | Patient complaints | Clinical characteristics of the stages |
|---|---|---|---|
| Stage 1 | There are no POMs | Infrequent headaches (cephalgia), difficulty falling asleep, ringing or noise in the head, rarely cardialgic (“heart”) pain | The ECG is almost unchanged, cardiac output increases exclusively with increased physical activity, hypertensive crises are extremely rare |
| Stage 2 | 1 or more injuries to vulnerable organs | Cephalgia becomes more frequent, angina attacks or shortness of breath from physical exertion occur, dizziness often occurs, crises appear more often, nocturia often develops - more frequent urination at night than during the day | Shift to the left of the left border of the heart on the ECG, level cardiac output increases insignificantly at optimal physical activity, increased pulse wave speed |
| Stage 3 | The emergence of dangerous associated (parallel) clinical conditions (ACC) | Symptoms of cerebrovascular and renal pathologies, coronary heart disease, heart failure | Catastrophes in the vessels of affected organs, decrease in stroke and minute volumes, high peripheral vascular resistance |
| Malignant headache | Critically high blood pressure values – more than 120 mm according to the “lower” indicator | Detectable changes in arterial walls, tissue ischemia, organ damage resulting in renal failure, significant visual impairment and other functional damage |
The abbreviation TPVR used in the table is total peripheral vascular resistance.
The presented tables would be incomplete without another consolidated list - the classification of hypertension by stages, degree and risk of complications from the heart and blood vessels (CVC).
Table 3.Classification of the risk of cardiovascular complications in hypertension
Determination of the degrees and stages of hypertension is necessary for the timely selection of adequate antihypertensive therapy and the prevention of cerebral or cardiovascular accidents.
ICD 10 code
The variety of variations of hypertension is also confirmed by the fact that in ICD 10 its codes are defined in section 4 from positions I10 to I13:
- I10 – essential (primary) hypertension, this category of ICD 10 includes hypertension stages 1, 2, 3. and malignant headache;
- I11 – hypertension with a predominance of heart damage (hypertensive heart disease);
- I12 – hypertensive disease with kidney damage;
- I13 is a hypertensive disease that affects the heart and kidneys.
The set of conditions manifested by an increase in blood pressure is represented by headings I10-I15, including symptomatic hypertension.
Today, antihypertensive therapy is based on 5 basic clusters of drugs for the treatment of hypertension:
- diuretics – medications with a diuretic effect;
- sartans – angiotensin II receptor blockers, ARBs;
- CCBs – calcium channel blockers;
- ACE inhibitors – angiotensin converting enzyme inhibitors, ACE;
- BB – beta-blockers (subject to background AF or ischemic heart disease).
The listed clusters of medications have undergone randomized clinical trials and have shown high effectiveness in preventing the development of cardiovascular complications.
Additional means modern methods Hypertension is often treated with new generation medications - centrally acting alpha-adrenergic agonists, renin inhibitors and I1-imidazoline receptor agonists. For these drug groups in-depth research were not carried out, but their observational study gave reason to consider them the drugs of choice for certain indications.
The best results are shown by combined therapeutic regimens with medications of different pharmacotherapeutic classes. The “gold” standard for the treatment of hypertension is considered to be a combination of ACE inhibitors and diuretics.
But standard treatment, unfortunately, is not suitable for everyone. It is worth looking at the table of features of the use of drugs, taking into account contraindications and other aspects, in order to assess the difficulty of selecting adequate drug treatment for hypertension individually for each patient.
Table 4. Groups of drugs used to treat hypertension (given in alphabetical order).
| Pharmacotherapeutic group | Unconditional contraindications | Use with caution |
|---|---|---|
| BPC – dihydropyridine derivatives | - | Tachyarrhythmic rhythm disorders, CHF |
| CCBs of non-dihydropyridine origin | Reduced left ventricular output, CHF, AV block 2-3 degrees. | - |
| BRA (sartans) | Renal artery stenosis, pregnancy, hyperkalemia | Reproductive capacity (to bear children) in female patients |
| Beta blockers | Bronchial asthma, AV block 2-3 degrees. | COPD (except BD with bronchodilator effect), impaired glucose tolerance (IGT), metabolic syndrome (MS), exercising and playing sports |
| Aldosterone antagonist class diuretics | Renal failure in chronic or acute form, hyperkalemia | |
| Thiazide class diuretics | Gout | Pregnancy, hypo- and hyperkalemia, IGT, MS |
| ACEI | Tendency to angioedema, renal artery stenosis, hyperkalemia, pregnancy | Reproductive ability of patients |
The selection of a suitable medication for the treatment of hypertension should be based on its classification, and taking into account parallel diseases and other nuances.
Lifestyle with hypertension
Let's consider what medications are relevant for hypertension, aggravated by parallel diseases, damage to vulnerable organs, and in special pathological situations:
- in patients with microalbuminuria and renal dysfunction, it is appropriate to take sartans and ACE inhibitors;
- for atherosclerotic changes - ACE and BCC inhibitors;
- with left ventricular hypertrophy ( frequent consequences GB) – sartans, BKK and ACE inhibitors;
- for persons who have suffered a mini-stroke, any of the listed antihypertensive drugs are indicated;
- persons with a previous heart attack are prescribed ACE inhibitors, beta-blockers, sartans;
- concomitant CHF involves the use of aldosterone antagonists, diuretics, beta-blockers, sartans and ACE inhibitors in the treatment of hypertension;
- for stable angina pectoris, CCBs and beta-blockers are recommended;
- for aortic aneurysm - beta-blockers;
- paroxysmal AF () requires the use of sartans, ACE inhibitors and beta-blockers or aldosterone antagonists (in the presence of CHF);
- Hypertension with underlying persistent AF is treated with beta-blockers and non-dihydropyridine CCBs;
- in case of damage to peripheral arteries, CCBs and ACE inhibitors are relevant;
- in the treatment of hypertension in those suffering from isolated systolic hypertension and the elderly, it is recommended to use diuretics, CCBs and sartans;
- for metabolic syndrome - sartans, CCBs, ACE inhibitors and their combinations with diuretics;
- in case of diabetes mellitus arising from hypertension - CCBs, ACE inhibitors, sartans;
- Pregnant women are allowed to treat hypertension with Nifedipine (CCB), Nebivolol or Bisoprolol (beta-blockers), Methyldopa (alpha-adrenergic agonist).
According to clinical guidelines, established by the results of the Congress of Cardiologists, held in Barcelona in June 2018, beta-blockers were excluded from the list of 1st-line drugs in the treatment of hypertension, where they were previously present. Now the use of beta blockers is considered justified in case of concomitant or ischemic heart disease.
Target blood pressure values in persons receiving antihypertensive therapy also underwent changes:
- for patients under 65 years of age, the recommended SBP values are 130 mmHg. Art., if they are well tolerated;
- the target for DBP is 80 mmHg. for all patients.
To consolidate the results of antihypertensive therapy, it is necessary to combine drug treatment with non-drug methods - improving life, correcting diet and physical activity.
Overweight and abdominal obesity, which usually indicate the presence of metabolic syndrome, are listed as the main causes of hypertension. Removing these risk factors will be a significant contribution to the treatment of hypertension.
The greatest effectiveness is shown by a significant reduction in the amount of salt - up to 5 g per day. Nutrition for hypertension is also based on limiting fats and sugar, avoiding fast food, snacks and alcohol, and reducing the number of drinks containing caffeine.
A diet for hypertension does not require completely abstaining from animal products. Required use low-fat varieties meat and fish, dairy products, cereals. A larger percentage of the diet should be given to vegetables, fruits, herbs and grains. It is advisable to completely remove carbonated drinks, sausages, smoked meats, canned food and baked goods from the menu. Non-drug treatment, based on improving the diet, is the main factor in the successful treatment of hypertension.
What effect does it have on the heart?
A common consequence of hypertension on the heart is left ventricular hypertrophy - an abnormal increase in the size of the heart muscle in the LV region. Why is this happening? An increase in blood pressure is caused by a narrowing of the arteries, which is why the heart is forced to function at an increased rate to ensure blood supply to the organs and its own. Work in increased load potentiates an increase in the size of the heart muscle, but the size of the vasculature in the myocardium ( coronary vessels) do not grow at the same speed, so the myocardium experiences a lack of oxygen and nutrients.
The response of the central nervous system is to launch compensation mechanisms that accelerate heart rate and constrict blood vessels. This provokes the formation vicious circle, which more often occurs with the progression of hypertension, because the longer the elevated blood pressure persists, the sooner the heart muscle hypertrophies. The way out of this situation is to start on time and adequate treatment hypertension.
Prevention memo
It is useful to take preventive measures to prevent the development of hypertension not only for people from a high-risk group (with hereditary factors, harmful conditions work, obesity), but also for all adults.
The memo on the prevention of hypertension contains the following points:
- maximum amount of salt – no more than 5-6 g per day;
- organizing and maintaining a daily routine with a fixed time for getting up in the morning, eating and going to bed;
- increasing physical activity through daily morning exercises, walking in the fresh air, feasible work in the garden, swimming or cycling;
- norm of night sleep – 7-8 hours;
- maintaining a normal weight; in case of obesity – weight loss measures;
- priority to products rich in Ca, K and Mg - egg yolks, low-fat cottage cheese, legumes, parsley, baked potatoes, etc.;
- an indispensable condition is getting rid of addictions: alcohol, nicotine;
Weight loss measures - carefully counting calories consumed, controlling fat intake (< 50-60 г в сутки), 2/3 которого должны быть plant origin, reducing the amount of whole milk products in the menu, sugar, honey, baked goods, chocolate products, rice and semolina.
In order to prevent hypertension, regular blood pressure measurements, periodic medical examinations and timely treatment detected pathological conditions.
Useful video
For more information about hypertension, watch this video:
Conclusions
- The concept of hypertension in medical literature used for primary or essential arterial hypertension, that is, hypertension of unknown origin.
- The prevalence of primary hypertension accounts for 90% of all cases of hypertension.
- Hypertension is a polyetiological disease, since it is caused simultaneously by several provoking factors.
What is the classification? Why is it extremely important to understand the danger of this pathology for modern man? Some people believe that constantly elevated blood pressure numbers are not dangerous to health, and that it is necessary to go to the hospital only when they are “off scale.” This is a fundamentally erroneous opinion, so knowing what classification exists today according to world organizations, what stages of the disease are distinguished and how it is treated will be of great help in the prevention of hypertension.
What is the essence of the problem
Hypertension is one of the most common cardiovascular diseases. New degrees and stages of hypertension are increasingly being classified.
Statistics show that in different countries Hypertension affects 10 to 20% of the active population. These numbers are a worldwide trend. Half of all patients with this diagnosis are not treated. The danger of this pathology is that it leads to a stroke or heart attack. The likelihood of developing the disease increases significantly with age. The disease leads to disability at a young age.
The latest data from the World Health Organization indicate that even teenagers are starting to suffer from arterial hypertension. People who are subject to frequent stress and negative emotions are most susceptible to pathology. According to the modern classification, there are different degrees of hypertension, forms, stages of the pathological process, and its further complications.
According to the recommendations of health care institutions, hypertension should be understood as an increase in blood pressure relative to normal, regardless of the cause. Primary or essential hypertension is an independent pathology. Today, the reasons for its appearance have not yet been fully elucidated. Different stages of secondary hypertension develop against the background of existing diseases of the heart, kidneys, and endocrine glands.
The disease is chronic. It is characterized by a steady increase in pressure. This means that there are always increased degrees of risk for the heart and blood vessels, because they work under increased load all the time.
Development of views on the classification of hypertension
The disease has been studied by doctors for centuries. During all this time, the classification of arterial hypertension by stages and types has undergone changes. Experts looked differently at the reasons for its appearance, clinical symptoms, blood pressure levels and characteristics of its stability, and more. Some of them have long been irrelevant.
The most modern is the WHO classification based on blood pressure indicators. It is customary to consider such indicators blood pressure as the norm and as deviations: 
- 120/80 mm. Hg Art. - the best indicator;
- from 120/80 to 129/84 - normal indicators;
- borderline indicators - 130/85 - 139/89 mm. Hg st;
- from 140/90 to 159/99 mm. Hg Art. - evidence that the patient is developing grade 1 hypertension;
- with arterial hypertension of the 2nd degree, the tonometer reading varies from 160/100 to 179/109 mm. Hg Art.;
- if a person’s blood pressure is recorded above 180/110 mm. Hg Art., he is diagnosed with hypertension degree 3.
Back in the 20s of the last century, doctors divided pathology into “pale” and “red”. Its shape was determined depending on the patient’s complexion. If he had cold extremities and pale face, which means he was diagnosed with the so-called pale type. On the contrary, when the blood vessels dilated, the patient’s face turned red, which means that he developed the “red” type of the disease. This classification did not take into account the stage and degree of the disease, and treatment was prescribed incorrectly.
Since the 30s. differentiated between benign and malignant forms. Benign was understood as a variant of the course of the disease when it progressed slowly. And if the disease developed quickly or began at a young age, then a malignant form was diagnosed.
Subsequently, the classification of hypertension was revised several times. Today, stages are distinguished depending on the magnitude of the change in blood pressure and its stability. The WHO classification of arterial hypertension is as follows:
- borderline hypertension - its first degree (the tonometer reading does not exceed 159/99 mm);
- moderate (2nd degree) - increased pressure to 179/109 mm;
- severe (3rd degree) - blood pressure rises above 180/110 mm.
In some classifiers, the table is supplemented with a fourth stage. With it, blood pressure is higher than 210/110 mm. Hg Art. This stage is considered very difficult.
Stages, forms of hypertension
Such a disease has not only degrees. Doctors distinguish between stages disease process depending on the damage to the body organs: 
- If a patient has stage 1 hypertension, he experiences a slight and short-lived increase in blood pressure. No complaints. The functioning of the heart and blood vessels is not impaired.
- At the 2nd stage of arterial hypertension, there is a persistent increase in blood pressure. The left ventricle is increasingly enlarged. A local narrowing of the vessels supplying the retina is diagnosed. Others pathological changes not registered.
- Arterial 3 is characterized by severe damage to all organs:
- heart failure, angina pectoris, heart attack;
- chronic kidney problems;
- acute cerebrovascular accidents - stroke, hypertensive encephalopathy, other circulatory disorders;
- hemorrhages in the fundus of the eye, swelling of the nerve of the eye;
- damage to peripheral blood vessels;
- aortic aneurysm.
There is another classification of arterial hypertension that takes into account options for increasing blood pressure. In this regard, the following forms of pathology are distinguished:
- systolic (in this case, only the “upper” pressure increases, and diastolic pressure may be normal);
- diastolic (diastolic pressure increases, while the “upper” pressure remains less than 140 mm Hg);
- systole-diastolic (in such a patient, regardless of the degree of hypertension, both types of pressure are equally elevated);
- labile form (the patient’s blood pressure rises only for a short time and goes away quickly).
The above modern classification takes into account almost all aspects related to increasing the tonometer readings. Depending on what stage a particular patient has, appropriate treatment is prescribed. It does not take into account other nuances of the manifestation of hypertension.
Some manifestations of arterial hypertension
The WHO classification of arterial hypertension does not take into account other manifestations and forms of the disease. This means that they are “apart” from the above stages and forms of pathology. The table of manifestations of hypertension will be slightly supplemented.
The most severe consequence of arterial hypertension is hypertensive crisis. The pressure inside the arteries rises to critical levels. Most often it occurs if the patient is diagnosed with 3. Due to persistently high blood pressure, he develops the following complications: 
- blood circulation in the brain is impaired;
- intracranial pressure rises sharply;
- oxygen starvation of the brain increases;
- dizziness and severe headache appear.
All this is accompanied by nausea and vomiting. With the hyperkinetic type of the disease, a person's diastolic pressure increases significantly. The hypokinetic form, on the contrary, is characterized by an increase in “lower” pressure. If the patient develops the eukinetic form of the disease, both numbers on the tonometer simultaneously increase.
Some degrees of arterial hypertension may be complicated by so-called refractory hypertension. In this case, the disease cannot be treated with medication. Sometimes the patient's condition does not improve, even if he has taken more than 3 medications.
This form of the disease can be confused and due to an inaccurate diagnosis, drug therapy will be ineffective. Refractory hypertension stage 2 or 3 can also be observed if the patient does not comply with all doctor’s prescriptions.
Finally, white coat hypertension is distinguished. In this case high blood pressure in a person is observed when he is in the hospital during medical procedures. In this case, it is customary to argue about an iatrogenic increase in pressure. It may seem harmless, but this is where its insidiousness lies. Such a patient needs to pay attention to his lifestyle and undergo a medical examination.
Risk factors for arterial hypertension
Any stage of hypertension has certain risk factors. Their exposure significantly increases the likelihood of a person developing dangerous complications. What are the main factors contributing to the development of arterial hypertension? This information Should be taken into account by anyone who has had several episodes of high blood pressure, regardless of the reasons: 
- Age (men over 55 years old and women over 65 years old). In case of unfavorable heredity, it is necessary to reverse special attention men and up to 55 years of age.
- Smoking. All cigarette consumers need to remember that their bad habit is the most important factor in the development of the disease.
- Increased cholesterol levels. For all patients, a total cholesterol level of more than 6.5 mmol/l is critical. The same indicators apply to HDL-C over 4 mmol/, and HDL-C over 1 mmol for male patients and 1.2 for female patients.
- Poor family history of cardiovascular pathologies (especially for men under 55 years of age and women under 65 years of age).
- Obesity by abdominal type(if men's waist circumference is over 102 cm or women's - 88 cm).
- Presence of C-reactive protein greater than 1 mg/dl.
- Impaired sugar tolerance.
- Physical inactivity.
- Increased fibrinogen content in the blood.
Such risk factors are especially relevant if the patient is diagnosed with stage 1 hypertension. If the disease has a second degree, then special attention should be paid to the following indicators:
- left ventricular hypertrophy;
- Ultrasound signs of the size of the artery wall or the presence of atherosclerotic growths;
- increase in serum creatinine level - over 115 µmol/l in males and over 107 µmol/l in females;
- the presence of microalbuminuria from 30 to 300 mg per day.
Other risk factors for stage 3 hypertension are: 
- age over 65 years for women and 55 years for men;
- dyslipidemia;
- unfavorable family history;
- cerebrovascular pathologies - ischemic stroke or hemorrhagic type, transient cerebral circulatory dysfunction;
- myocardial infarction;
- kidney disease caused by diabetes mellitus;
- severe proteinuria;
- severe degree of renal failure;
- peripheral artery damage;
- swelling of the optic nerve.
Features of malignant hypertension
Hypertension of grade 3-A or 3-B may have a malignant course. This is due to the patient’s lifestyle, psychological stress, and unfavorable environmental situation. Malignant hypertension is very dangerous disease If left untreated, the complications it causes can be fatal.
Main Features malignant hypertension the following: 
- Sharply increased blood pressure. Diastolic readings can reach 220 and even exceed it.
- Changes in the fundus. This significantly worsens vision. In severe cases, complete blindness occurs.
- Kidney failure.
- Migraines develop.
- Patients feel weak and very tired.
- Sometimes there is a drop in weight and appetite.
- Fainting often occurs.
- The functioning of the digestive system is disrupted - patients suffer from nausea and vomiting.
- Registered sharp jump blood pressure at night.
Malignant hypertension is caused by the following diseases:
- Pheochromocytoma. This pathological process in the adrenal cortex. As a result of inflammation, substances are formed in the body that provoke a sudden increase in blood pressure.
- Parenchymal diseases.
- Violation of the condition of blood vessels in the kidneys. Because of this, blood flow to this organ significantly deteriorates, which is why the patient develops so-called renovascular hypertension.
The risk factors for this hypertension are as follows:
- long-term smoking (patients who smoke more than a pack of cigarettes per day are at risk);
- alcohol abuse;
- endocrine disorders;
- pregnancy (pregnancy with a malignant course may develop against its background);
- overwork and prolonged physical activity;
- stress, emotional breakdowns.
Treatment of all these conditions should only be carried out under the supervision of a physician.
Renal hypertension
If a patient is diagnosed with hypertension, classifying all its types can be very difficult. This happens when high blood pressure is caused by problems with the kidneys. U individual categories patients can be observed for a long time increased performance systolic and diastolic pressure. Qualified assistance consists in the fact that the patient undergoes complex treatment kidney 
This pathology develops with changes in normal operation excretory system. Those most susceptible to this type of hypertension are those with a tendency to edema. Then decay products, salts and other substances are not removed from the blood.
Because of complex processes triggered in the body due to chronic fluid retention, the patient’s lumen of the arteries that supply the kidneys narrows. At the same time, the synthesis of prostaglandins decreases, the main function of which is to maintain normal arterial tone. Therefore, in such patients, blood pressure is consistently elevated.
It is extremely important in the regulation of blood pressure normal function adrenal cortex. If it functions intermittently, then hormonal balance in the body is disrupted. And this leads to constantly elevated blood pressure.
Distinctive symptoms of such hypertension: 
- young age;
- the patient’s blood pressure rises suddenly, without depending on previous emotional or physical stress;
- asymmetrical pressure increase;
- swelling of the legs;
- hyperemia of the blood vessels of the eyes (possible hemorrhage in the retina of the eye);
- severe damage to the optic nerve.
Therapy for such a disease is associated with the treatment of the underlying disease. Medicines are prescribed to slow down the production of renin.
Hypertension has enough complex classification. This is due to the fact that the factors for the development of such pathology are extremely diverse. The clinical manifestations and forms of manifestation of the disease depend on them and on the pathogenesis. Regardless of the degree and stage of hypertension, before starting treatment for the disease, a comprehensive diagnosis of the patient is prescribed, and only after that can specially selected drugs be prescribed. Comprehensive treatment for each patient medicines will be individual, arterial hypertension occurs differently for everyone.
Arterial hypertension in diabetes mellitus develops quite often. Basically, an increase in pressure occurs when a complication such as nephropathy appears against the background of chronic glycemia.
Hypertension is dangerous for diabetics because it can lead to vision loss, kidney failure, stroke or heart attack. To prevent unwanted consequences from occurring, it is important to normalize blood pressure in a timely manner.
A gentle and effective way to treat high blood pressure is a hypertensive enema. The procedure has a rapid laxative effect, removes excess fluid from the body, and reduces intracranial pressure. But before resorting to such manipulations, you should study the features of their implementation and become familiar with the contraindications.
What is a hypertensive enema?
In medicine they call it hypertensive special solution. Its osmotic pressure is higher than normal blood pressure. Therapeutic effect achieved by combining isotonic and hypertonic solutions.
When two types of liquids are combined, separated by a semi-permeable membrane (in the human body these are the membranes of cells, intestines, blood vessels), water enters the sodium solution from the physiological one along a concentration gradient. This physiological principle is the basis for the use of enemas in medical practice.
The principle of the procedure for stabilizing blood pressure is similar to that used when performing a regular enema. This is the filling of the solution in the intestines and the subsequent removal of fluid during bowel movements.
This manipulation is effective for severe swelling of various etiologies and constipation. To administer a hypertensive enema, an Esmark mug is often used. It is possible to use a special heating pad with a hose and tip.
Hypertensive enema removes from the body excess water, due to which the hypotensive effect is achieved, and hemorrhoids- dissolve. The procedure also helps normalize intracranial pressure.
Advantages of a hypertensive enema:
- comparative safety;
- ease of implementation;
- high therapeutic effectiveness;
- easy recipe.
Many doctors admit that an enema for hypertension lowers blood pressure much faster than oral administration. antihypertensive drugs. This is due to the fact that the medicinal solution is instantly absorbed into the intestines and then penetrates into the blood.
Types of solutions and methods of their preparation
Sugar level
According to their purpose, enemas are divided into alcoholic (removes psychotropic substances), cleansing (prevents the occurrence of intestinal diseases) and medicinal. The latter involve the introduction of medicinal solutions into the body. Also, various oils can be used for the procedure, which are especially effective for constipation.
Hypertensive enema is carried out with different solutions, but magnesium sulfate and magnesium sulfate are often used. These substances can be purchased at any pharmacy. They almost instantly increase osmotic pressure, which allows them to remove excess water from the body. The patient's condition returns to normal 15 minutes after the therapeutic procedure.
A hypertonic solution can be prepared at home. For this purpose, prepare 20 ml of distilled or boiled water (24-26°C) and dissolve a tablespoon of salt in it.
It is noteworthy that when preparing a saline solution, it is better to use dishes made of enamel, ceramics or glass. This way, aggressive sodium will not react with materials.
Since salt irritates the intestinal mucosa, to soften its effect the following is added to the solution:
- glycerol;
- herbal decoctions;
- vegetable oils.
To prepare a nutrient solution for hypertensive enema of an adult, Vaseline, sunflower or refined olive oil are used. Add 2 large spoons of oil to 100 ml of clean water.
Indications and contraindications
Cleansing with isotonic and hypertonic solutions is carried out in order to normalize blood pressure. However, enemas can be effective for other painful conditions.
Thus, the procedure is indicated for severe and atonic constipation, increased intracranial or intraocular pressure, and poisoning of various etiologies. Manipulation is also prescribed in case of dysbacteriosis, sigmoiditis, proctitis.
Hypertensive enema can be performed for cardiac and renal edema, hemorrhoids, and intestinal helminthiases. Another procedure is prescribed before diagnostic examinations or operations.
The hypertonic bowel cleansing method is contraindicated for:
- hypotension;
- bleeding in the gastrointestinal tract;
- malignant formations, polyps localized in the digestive tract;
- peritonitis or appendicitis;
- inflammatory processes in the anorectal area (fistulas, fissures, ulcers, the presence of ulcers in the anorectal area);
- rectal prolapse;
- severe heart failure;
- ulcer of the gastrointestinal tract.
Also, the hypertensive enema method is contraindicated for diarrhea, abdominal pain of various etiologies, solar or thermal overheating and water-electrolyte balance disorders.
Preparation and technique of enema
After hypertonic solution was prepared, you should carefully prepare for the procedure. In the beginning, you need to stock up on an enema bulb, an Esmark mug or a Janet syringe.
You will also need a wide basin or bowl that will be used for emptying. To perform the medical procedure comfortably, you need to purchase medical oilcloth, gloves, ethanol, and petroleum jelly.
The couch on which the patient will lie is covered with oilcloth and a sheet on top. When preparatory stage completed, proceed to the actual execution of the procedure.
The algorithm for performing a hypertensive enema is not complicated, so the manipulation can be carried out both in a clinic and at home. It is recommended to empty your bowels before the procedure.
First, you should heat the medicinal solution to 25-30 degrees. You can control the temperature using a simple thermometer. Then the patient lies on the bed on his left side, bends his knees, pulling them towards the peritoneum.
Technique for performing a hypertensive enema:
- The nurse or person performing the cleansing procedure puts on gloves and coats the enema tip with Vaseline and inserts it into the anal area.
- Using circular movements, the tip must be advanced into the rectum to a depth of 10 cm.
- Next, a hypertonic solution is gradually introduced.
- When the enema is empty, the patient should turn over on his back, which will help him retain the solution for about 30 minutes.
A basin should be placed next to the couch where the patient lies. Often the urge to defecate occurs 15 minutes after completion of the procedure. If the hypertensive enema was done correctly, then during and after it there should be no unpleasant sensations.
After the procedure, it is always necessary to clean the tip or tube of the device used. For this purpose, the equipment is soaked for 60 minutes in a chloramine solution (3%).
A cleansing, hypertonic, siphon, nutritional, medicinal and oil enema is performed only in medical conditions. Since for therapeutic manipulation you will need special system, including a rubber, glass tube and funnel. In addition, nutritional enemas are contraindicated in any case, because glucose is present in the solution.
If a hypertensive enema is given to children, then a number of nuances should be taken into account:
- The concentration and volume of the solution decreases. If sodium chloride is used, 100 ml of liquid will be needed, and if magnesium sulfate is used, 50 ml of water will be required.
- During the procedure, the child should be immediately placed on his back.
- The technique for performing manipulation using a regular enema or pear is similar to that described above, but when using a siphon enema, the algorithm is different.
Side effects
After this type of enema, as with any medical procedure, a number of problems may arise. side effects. Negative reactions appear with frequent use of a cleansing enema.
Thus, the procedure can lead to intestinal spasm and increased peristalsis, which will contribute to the retention of the injected solution and feces in the body. In this case, the intestinal walls stretch, and intra-abdominal pressure increases. This causes aggravation chronic inflammation in the small pelvis, leads to rupture of adhesions and penetration of their purulent secretion into the peritoneum.
The sodium solution irritates the intestines, which helps wash out the microflora. As a result, chronic colitis or dysbacteriosis may develop.
How a hypertensive enema is done is described in the video in this article.
For quotation: Preobrazhensky D.V. NEW APPROACHES TO THE TREATMENT OF ARTERIAL HYPERTENSION // Breast Cancer. 1999. No. 9. S. 2
Since 1959, World Health Organization (WHO) experts have published recommendations for the diagnosis, classification and treatment of arterial hypertension based on the results of epidemiological and clinical studies. Since 1993, such recommendations have been prepared by WHO experts together with the International Society of Hypertension. In the Japanese city of Fukuoka, from September 29 to October 1, 1998, the 7th meeting of WHO and the International Society of Hypertension (ISH) experts was held, at which new recommendations for the treatment of arterial hypertension were approved. These recommendations were published in February 1999 (1999 WHO-ISH guidelines for the management of hypertension). Below we provide a brief summary of their main provisions.
WITH 1959 World Health Organization (WHO) experts publish recommendations for the diagnosis, classification and treatment of arterial hypertension, based on the results of epidemiological and clinical studies. Since 1993, such recommendations have been prepared by WHO experts together with the International Society of Hypertension (Intern a tional Society of Hypertension). In the Japanese city of Fukuoka, from September 29 to October 1, 1998, the 7th meeting of WHO and the International Society of Hypertension (ISH) experts was held, at which new recommendations for the treatment of arterial hypertension were approved. These recommendations were published in February 1999 (1999 WHO-ISH guidelines for the management of hypertension). Below we provide a brief summary of their main provisions.
Definition and classification of arterial hypertension
In the 1999 WHO-IOG recommendations, arterial hypertension is defined as a systolic blood pressure (BP) level of 140 mmHg. Art. or more, and/or a diastolic blood pressure level equal to 90 mmHg. Art. or more, in people who are not receiving antihypertensive drugs. Given the significant spontaneous fluctuations in blood pressure, the diagnosis of hypertension should be based on the results of repeated blood pressure measurements during several visits to the doctor.
Table 1. Classification of blood pressure
| AD class* |
Blood pressure, mmHg Art. |
|
| systolic | diastolic | |
| Optimal blood pressure |
< 120 |
< 80 |
| Normal blood pressure |
< 130 |
< 85 |
| Increased normal blood pressure |
130-139 |
85-89 |
| Arterial hypertension | ||
| 1st degree ("soft") |
140-159 |
90-99 |
| Subgroup: borderline |
140-149 |
90-94 |
| 2nd degree ("moderate") |
160-179 |
100-109 |
| 3rd degree ("severe") |
i 180 |
і 110 |
| Isolated c istolic hypertension |
і 140 |
< 90 |
| Subgroup: borderline |
140-149 |
< 90 |
|
* If systolic and diastolic blood pressure are in different classes, the patient’s blood pressure level is assigned to a higher class. |
||
Depending on the level of systolic and diastolic blood pressure, three degrees of arterial hypertension are distinguished ( ). In the 1999 WHO-ITF classification, grades 1, 2, and 3 arterial hypertension correspond to the terms “mild,” “moderate,” and “severe” hypertension, which were used, for example, in the 1993 WHO-ITF guidelines.
In contrast to the 1993 guidelines, the new guidelines state that approaches to the treatment of hypertension in the elderly and isolated systolic hypertension should be the same as approaches to the treatment of classical hypertension in middle-aged individuals.
Long-term prognosis assessment
In 1962, WHO expert recommendations first proposed distinguishing three stages of arterial hypertension depending on the presence and severity of target organ damage. For many years it was believed that in patients with target organ damage, antihypertensive therapy should be more intensive than in patients without damage to such organs.
The new classification of arterial hypertension by WHO-IOG experts does not provide for the identification of stages in the course of hypertension. The authors of the new recommendations draw attention to the results of the Framingham study, which showed that in patients with arterial hypertension, the risk of developing cardiovascular complications over a 10-year observation period depended not only on the degree of increase in blood pressure and the severity of target organ damage, but also on other factors risk and associated diseases. After all, it is known that such clinical conditions, as diabetes mellitus, angina pectoris or congestive heart failure have a more adverse effect on the prognosis of patients with arterial hypertension than the degree of increase in blood pressure or left ventricular hypertrophy.
When choosing therapy in patients with arterial hypertension, it is recommended to take into account all factors that may affect the prognosis ().
Before initiating therapy, each patient with hypertension must be assessed for their absolute risk of cardiovascular complications and assigned to one of four risk categories depending on the presence or absence of cardiovascular risk factors, end-organ damage, and comorbidities ( ).
Goal of antihypertensive therapy
The goal of treating a patient with hypertension is to reduce the risk of cardiovascular complications as much as possible. This means that it is necessary not only to reduce high blood pressure, but also to act on all other reversible risk factors (smoking, hypercholesterolemia, diabetes mellitus), and also treat concomitant diseases. In young and middle-aged patients, as well as in patients with diabetes, if possible, blood pressure should be maintained at an “optimal” or “normal” level (up to 130/85 mm Hg). In elderly patients, blood pressure should be reduced to at least an “elevated normal” level (up to 140/90 mm Hg; see).
Table 2. Prognostic factors for arterial hypertension
| A. Risk factors for cardiovascular disease I. Used for risk assessment . Levels of systolic and diastolic blood pressure (arterial hypertension of the 1st - 3rd degree) . Men over 55 years old . Women over 65 years old . Smoking . Serum total cholesterol level more than 6.5 mmol/l(250 mg/dl) . Diabetes mellitus . Indications of premature development of cardiovascular disease in a family history II. Other factors that have an adverse effect for forecast . Reduced levels high lipoprotein cholesterol density . Increased levels lipoprotein cholesterol low density . Microalbuminuria (30 - 300 mg/day) in diabetes mellitus . Impaired glucose tolerance . Obesity . Sedentary lifestyle . Elevated fibrinogen levels . High risk socioeconomic group . High risk ethnic group . Geographical region high risk B. Target organ damage . Left ventricular hypertrophy (as determined by electrocardiography, echocardiography, or organ radiography chest) . Proteinuria (>300 mg/day) and/or a slight increase in plasma creatinine concentration (1.2-2.0 mg/dL) . Ultrasound or X-ray angiographic signs of atherosclerotic lesions of the carotid, iliac and femoral arteries, aorta . Generalized or focal narrowing of the retinal arteries C. Associated clinical conditions Vascular disease brain . Ischemic stroke . Hemorrhagic stroke . Transient cerebrovascular accident Heart disease . Myocardial infarction . Angina pectoris . Revascularization coronary arteries . Congestive heart failure Kidney disease . Diabetic nephropathy . Kidney failure(plasma creatinine content above 2.0 mg/dl) Vascular disease . Dissecting aneurysm . Damage to arteries with clinical manifestations Severe hypertensive retinopathy . Hemorrhages or exudates . Papilledema |
| Note. Target organ damage corresponds to stage II of hypertension according to the 1996 WHO expert classification, and concomitant clinical conditions - Stage III diseases. |
Thus, in groups of patients with high and very high risk drug therapy must begin immediately. In the group of patients with average risk ( ) treatment of arterial hypertension begins with lifestyle changes. If non-drug interventions within 3-6 months do not lead to a decrease in blood pressure below 140/90 mm Hg. Art., it is recommended to prescribe antihypertensive drugs.
In the group of low-risk patients, treatment also begins with non-drug methods, but The observation period increases to 6-12 months. If after 6-12 months the blood pressure remains at 150/95 mm Hg. Art. or higher, begin drug therapy (regimen).
The intensity of antihypertensive therapy also depends on which risk group the patient belongs to. The higher the overall risk of cardiovascular complications, the more important it is to reduce blood pressure to an appropriate level ("optimal", "normal" or "elevated normal") and to combat other risk factors. As calculations show, with the same degree of arterial hypertension, the effectiveness of antihypertensive therapy in patients with high and very high risk is much higher than in patients with low risk. Thus, antihypertensive therapy, which reduces blood pressure by an average of 10/5 mmHg. Art., allows you to prevent less than 5 serious cardiovascular complications per 1000 patient-years of treatment in patients with low risk and more than 10 complications in patients with very high risk.
Lifestyle change
Lifestyle changes should be recommended to all patients with hypertension, although there is currently no direct evidence that non-pharmacological interventions, by lowering blood pressure, reduce the risk of cardiovascular complications. It has been proven that non-drug methods, in addition to lowering blood pressure, also reduce the need for antihypertensive drugs and increase their effectiveness, and also help in the fight against other risk factors.
Table 3.
Risk level of cardiovascular complications
in patients with arterial hypertension of varying degrees in order to determine the prognosis*
| Risk factors (other than hypertension) and medical history | Risk level for arterial hypertension | ||
|
Stage 1 (mild hypertension) AD 140-159/90- 99 mmHg Art. |
|||
| No other factors risk |
Short |
Average |
High |
| 1-2 other factors
risk |
Average |
Average |
Very high |
| 3 or more others risk factors, POM or sugar diabetes |
High |
High |
Very high |
| Related disease** |
Very High |
Very high |
Very high |
| *Typical examples of the risk of developing a cerebral stroke or heart attack over 10 years: low risk - less than 15%; average risk - approximately 15-20%; high risk - approximately 20-30%; very high risk - 30% or higher.
*
.
|
|||
Quitting smoking is especially important. Smoking cessation appears to be the most effective non-pharmacological way to reduce the risk of cardiovascular and non-cardiovascular diseases in patients with arterial hypertension.
Obese patients should be advised to reduce body weight by at least 5 kg. This change in body weight not only causes a decrease in blood pressure, but also has a beneficial effect on other risk factors such as insulin resistance, diabetes mellitus, hyperlipidemia and left ventricular hypertrophy. The antihypertensive effect of weight loss is enhanced by a simultaneous increase in physical activity, limiting the consumption of table salt and alcoholic beverages.
There is evidence that regular alcohol consumption in moderation (up to 3 glasses a day) reduces the risk of developing coronary heart disease (CHD). At the same time, a linear dependence of blood pressure levels (or the prevalence of arterial hypertension) in populations on the amount of alcoholic beverages consumed was discovered. It has been established that alcohol weakens the effects of antihypertensive therapy, and its pressor effect persists for 1 - 2 weeks. For this reason, patients with arterial hypertension who drink alcohol should be advised to limit their alcohol consumption (no more than 20-30 ml per day for men and no more than 10-20 ml per day for women). Patients who abuse alcohol should be advised high risk development of cerebral stroke.
The results of randomized studies have shown that reducing dietary sodium intake from 180 to 80-100 mmol per day leads to a decrease in systolic blood pressure by an average of 4-6 mmHg. Art. Even a small restriction of sodium intake from food (by 40 mmol per day) significantly reduces the need for antihypertensive drugs. drugs. Patients with arterial hypertension should be advised to limit their dietary sodium intake to less than 100 mmol per day, which corresponds to less than 6 g of table salt per day.
Patients with arterial hypertension should reduce their consumption of meat and fatty foods and at the same time increase your consumption of fish, fruits and vegetables. Patients who lead a sedentary lifestyle should be advised to have regular physical exercise outdoors (30-45 minutes 3-4 times a week). Brisk walking and swimming are more effective than running and reduce systolic blood pressure by approximately 4-8 mmHg. Art. In contrast, isometric exercise (eg, weight lifting) may increase blood pressure.
Drug therapy
The main antihypertensive drugs are diuretics, b -adrenergic blockers, calcium antagonists, angiotensin converting enzyme (ACE) inhibitors, AT blockers 1 -angiotensin receptors and a 1 - adrenergic blockers. In some countries of the world, reserpine and methyldopa are often used in the treatment of arterial hypertension.
Different classes of antihypertensive drugs reduce blood pressure to approximately the same extent, but differ in the nature of side effects.
Table 4. Recommendations for the selection of antihypertensive drugs
| Group of drugs |
Indications |
Contraindications |
||
| Mandatory | Possible | mandatory | possible | |
| Diuretics | Heart failure
Accuracy + Elderly age + Systolic hypertension |
Diabetes mellitus | Gout | Dyslipidemia Sexually active men |
| b -Blockers | Angina + After
myocardial infarction + tachyarrhythmias |
Heart failure
accuracy + Pregnant- ness + Sugar di- abeth |
Bronchial asthma
and chronic ob- structural disease Pulmonary obstruction + Heart block* |
Dyslipidemia + Athletes and physical chesically active patients + lesion peripheral arterial therium |
| ACE inhibitors | Heart failure
accuracy + Dysfunction- tion of the left ventricle ka + After a heart attack myocardium + Diabetic nephropathy |
Pregnancy + Hyperkalemia | Double-sided glass
renal arterial disease riy |
|
| Calcium antagonists
tion |
Angina + Life-
age + Systo- personal hypertension(****) |
Peripheral damage
rical arteries |
Heart block** | Congestive heart
failure*** |
| a1-blockers | Hypertrophy pre-
static gland |
Violation of tolerance
affinity for glucose + Dyslipidemia |
Orthostatic hy-
potonia |
|
| AT blockers 1 - Angiotensin receptors |
Cough, called |
Heart failure-
Accuracy |
Pregnancy + Double-sided glass renal arterial disease rium + Hyperkalemia |
|
| * Atrioventricular block II - III degree. ** Atrioventricular block II - III degree during treatment with verapamil or diltiazem. *** For verapamil or diltiazem. ****In fact, in patients with isolated systolic hypertension, only dihydropyridine calcium antagonists and, in particular, nitrendipine have been found to have a beneficial effect. As for verapamil and diltiazem, their effectiveness and safety in isolated systolic hypertension, to our knowledge, have not been studied in controlled studies. (Note from the authors). |
||||
Several dozen randomized controlled studies have proven the ability long-term therapy diuretics and beta-blockers to prevent cardiovascular complications in patients with arterial hypertension. There is much less evidence of a beneficial effect of calcium antagonists and ACE inhibitors on long-term prognosis. There is not yet sufficiently convincing evidence that a 1 - adrenergic blockers and AT blockers 1 -angiotensin receptors may improve long-term prognosis in patients with arterial hypertension. However, it is assumed that in patients with arterial hypertension, the beneficial effect of antihypertensive therapy on prognosis depends mainly on the degree of blood pressure reduction achieved, and not on the class of drug.
Each of the main classes of antihypertensive drugs has certain advantages and disadvantages that must be taken into account when choosing a drug for initial therapy ().
For initial treatment, low doses of antihypertensive drugs are recommended to minimize side effects. In cases where a low dose of the first drug produces a good antihypertensive effect, it is advisable to increase the dose of this drug to reduce blood pressure to the desired level. If ineffective or poor tolerance of the first antihypertensive drug, its dose should not be increased, but another drug with a different mechanism of action should be added. You can also replace one drug with another.
Abbreviations: SBP - systological blood pressure; DBP - diastolic blood pressure;
AH - arterial hypertension;
POM - target organ damage; SCS - associated clinical conditions
In the HOT (Hypertension Optimal Treatment) study, a stepwise regimen for prescribing antihypertensive drugs worked well. For initial therapy, a prolonged form of the calcium antagonist felodipine was used at a dose of 5 mg/day. At the second step, an ACE inhibitor or b was added to felodipine retard - adrenergic blocker. On the third degree daily dose felodipine retard was increased to 10 mg. At the fourth stage, the dose of the ACE inhibitor was doubled or b-adrenergic blocker, and on the fifth, a diuretic was added if necessary.
It is best to use long-acting antihypertensive drugs that provide 24-hour blood pressure control when taken once a day. Examples of long-acting antihypertensive drugs include: b -adrenergic blockers such as betaxolol and metoprolol retard, ACE inhibitors such as perindopril, trandolapril and fosinopril, calcium antagonists such as amlodipine, verapamil and felodipine retard, AT blockers 1-angiotensin receptors, like valsartan and irbesartan. Monitors blood pressure a 1 for 24 hours - long-acting adrenergic blocker doxazosin.
The benefits are long lasting active drugs are that they improve the adherence of patients with arterial hypertension to treatment and reduce fluctuations in blood pressure during the day. It is believed that antihypertensive therapy,which provides a more uniform reduction in blood pressure throughout the day, more effectively prevents the development of cardiovascular complications and target organ damage in patients with arterial hypertension.
Diuretics
.
Diuretics remain one of the most valuable classes of antihypertensive drugs. They are significantly cheaper than other classes of antihypertensive drugs. Diuretics are highly effective and generally well tolerated when administered in low doses (not more than 25 mg of hydrochlorothiazide or equivalent doses of other drugs). Controlled studies have demonstrated the ability of diuretics to prevent serious cardiovascular complications such as cerebral stroke and coronary artery disease. In the 5-year randomized SHEP trial (S y stolic Hypertension in the Elderly Program), in which chlorthalidone was used for initial therapy, the incidence of cerebral stroke and coronary complications in the study group was 36 and 27% lower, respectively, than in the control group. That's why It is believed that diuretics are particularly indicated for the treatment of elderly patients with isolated systolic hypertension.
b
-Adrenergic blockers
.
b -Adrenergic blockers are inexpensive, effective and safe antihypertensive drugs. They can be used both for monotherapy of arterial hypertension and in combination with diuretics, dihydropyridine calcium antagonists and α-blockers. Although heart failure is certainly a contraindication to the use of beta-blockers in usual doses, there is evidence to support the beneficial effects of some beta-blockers (particularly bisoprolol, carvedilol and metoprolol) in some patients with heart failure when used at very low levels at the start of therapy. doses Should not be prescribed b - adrenergic blockers for patients with chronic obstructive pulmonary diseases and damage to peripheral arteries.
ACE inhibitors. ACE inhibitors are effective and safe antihypertensive drugs, the cost of which has decreased significantly in recent years. The effectiveness and safety of ACE inhibitors such as captopril, lisinopril, enalapril, ramipril, and fosinopril have been best studied in randomized studies. It has been established that ACE inhibitors are especially effective in reducing mortality in patients with heart failure and preventing the progression of nephropathy in patients with insulin-dependent diabetes mellitus (type I). The most common side effect ACE inhibitors are a dry cough, the most dangerous is angioedema, which, however, is extremely rare.
Calcium antagonists. All calcium antagonists have high antihypertensive efficacy and good tolerability. The ability of calcium antagonists (in particular, nitrendipine) to prevent the development of cerebral stroke in elderly patients with isolated systolic hypertension has been proven. Long-acting calcium antagonists (eg amlodipine, verapamil and felodipine retard) should be used preferentially and short-acting drugs should be avoided if possible.
AT blockers
1
-angiotensin receptors. AT blockers 1 -angiotensin receptors have many properties that make them similar to ACE inhibitors. In particular, they, like ACE inhibitors, are especially useful in patients with heart failure. The advantage of AT blockers 1 -angiotensin receptors (for example, such as valsartan, irbesartan, losartan, etc.) before ACE inhibitors is a low incidence of side effects. For example, they do not cause coughing. There is not yet sufficient evidence of the ability of AT blockers 1 -angiotensin receptors decrease increased risk cardiovascular complications in patients with arterial hypertension.
a
1
-Adrenergic blockers.
a 1 -Adrenergic blockers are effective and safe antihypertensive drugs, but so far there has been no sufficient evidence of their ability to prevent the development of cardiovascular complications in patients with arterial hypertension. Main side effect a 1 -adrenergic blockers - orthostatic hypotension, which is especially pronounced in elderly patients. Therefore, at the beginning of treatment a 1-adrenergic blockers, it is important to measure blood pressure in the patient’s position, not only sitting, but also standing. a 1 -Adrenergic blockers may be useful in the treatment of hypertension in patients with dyslipidemia or impaired glucose tolerance. When treating a 1 -Adrenergic blockers should be given preference to doxazosin, the antihypertensive effect of which lasts up to 24 hours after oral administration, over short-acting prazosin.
Antiplatelet and hypocholesterolemic therapy
Considering that in patients with arterial hypertension, the high overall risk of cardiovascular complications is associated not only with elevated blood pressure, but also with other factors, it is not enough to use only antihypertensive drugs to reduce the risk.
The randomized HOT trial showed that in patients with hypertension receiving effective antihypertensive therapy, the addition of low doses aspirin(75 mg/day) can significantly reduce the risk of serious cardiovascular complications (by 15%), including myocardial infarction (by 36%).
A number of randomized studies have established the high effectiveness of cholesterol-lowering drugs from the group of statins during primary and secondary prevention IHD in individuals with different levels of cholesterol in the blood. The effectiveness and safety of long-term administration of statins such as lovastatin, pravastatin and simvastatin have been most well studied. The use of atorvastatin and cerivastatin, which are superior to other statins in terms of the severity of their hypocholesterolemic effect, seems promising.
The data obtained in these studies allow us to recommend the use of aspirin and statins (in combination with antihypertensive drugs) in the treatment of patients with arterial hypertension and a high risk of developing coronary artery disease. Thus, the new WHO-IOG recommendations for the treatment of arterial hypertension propose slightly different approaches to the assessment and management of patients with high blood pressure than in the recommendations of 1993. WHO-IOG experts draw attention to the importance of assessing the overall cardiovascular risk in patients with arterial hypertension. -vascular complications, and not just the condition of target organs. In this regard, treatment should be aimed at both reducing high blood pressure and other modifiable risk factors. The goal of antihypertensive therapy has been determined, which is to maintain blood pressure below 130/85 mmHg. Art. in young and middle-aged patients and those suffering from diabetes mellitus and at levels below 140/90 mm Hg. Art. in elderly patients. Blockers
AT 1 -angiotensin receptors are included in the number of first-line drugs for the treatment of arterial hypertension.
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