A. V. Bilchenko

On June 9, within the framework of the Congress of the European Society for the Study of Hypertension (ESH), a draft of new ESH / ESC Recommendations for the treatment of hypertension (AH) was presented, which will significantly change the approaches to the treatment of patients with hypertension.

Definition and classification of hypertension

The ESH / ESC experts decided to leave the previous recommendations unchanged and classify blood pressure (BP), depending on the level recorded during the "office" measurement (that is, measured by a doctor at a clinic appointment), to "optimal", "normal "," High normal "and 3 degrees of hypertension (recommendation class I, level of evidence C). In this case, hypertension is defined as an increase in "office" systolic blood pressure (SBP) ≥140 mm Hg. Art. and / or diastolic blood pressure (DBP) ≥90 mm Hg. Art.

However, given the importance of "out-of-office" blood pressure measurement and differences in blood pressure levels in patients with different measurement methods, the ESH / ESC Guidelines for the treatment of hypertension (2018) include a classification of reference blood pressure levels for classifying hypertension when using "home" self-measurement and ambulatory blood pressure monitoring ( AMAD) (Table 1).

The introduction of this classification makes it possible to diagnose hypertension on the basis of out-of-office measurement of blood pressure, as well as various clinical forms of hypertension, primarily “masked hypertension” and “masked normotension” (white coat hypertension).

Diagnostics

To diagnose hypertension, the doctor is recommended to re-measure blood pressure in the office according to a method that has not undergone changes, or to evaluate the out-of-office measurement of blood pressure (home self-measurement or AMAD) if it is organizationally and economically feasible. Thus, although “office” measurement is recommended for screening hypertension, out-of-office BP measurement methods can be used to make the diagnosis. It is recommended to carry out in certain clinical situations out-of-office measurement of blood pressure (home self-measurement and / or AMP) (Table 2).

In addition, AMAD is recommended to assess the level of blood pressure at night and the degree of its decrease (in patients with sleep apnea, diabetes mellitus (DM), chronic kidney disease (CKD), endocrine forms of hypertension, autonomic regulation disorders, etc.).

When performing a screening repeated measurement of "office" blood pressure, depending on the result obtained, the ESH / ESC Guidelines for the treatment of hypertension (2018) propose a diagnostic algorithm using other methods for measuring blood pressure (Fig. 1).

Unresolved, from the point of view of ESH / ESC experts, remains the question of which of the methods for measuring blood pressure to use in patients with permanent atrial fibrillation. There are also no data from large comparative studies indicating that any method of out-of-office blood pressure measurement has advantages in predicting large cardiovascular events compared to “office” measurement when monitoring blood pressure during therapy.

Assessment of cardiovascular risk and its reduction

The methodology for assessing the total CV risk has not changed and is more fully presented in the ESC Guidelines for the Prevention of Cardiovascular Diseases (2016). It is proposed to use the European risk assessment scale SCORE to assess the risk in patients with grade 1 hypertension. However, it is indicated that the presence of risk factors not taken into account by the SCORE scale can significantly affect the total CV risk in a patient with hypertension.

The number of risk factors included new ones, such as the level of uric acid, early menopause in women, psychosocial and socio-economic factors, heart rate (HR) at rest> 80 beats / min (Table 3).

Also, the assessment of CV risk in hypertensive patients is influenced by the presence of target organ damage (TOM) and diagnosed CV diseases, diabetes mellitus or kidney disease. There were no significant changes in the ESH / ESC recommendations (2018) regarding the detection of POM in hypertensive patients.

As before, basic tests are offered: electrocardiographic (ECG) study in 12 standard leads, determination of the albumin / creatinine ratio in urine, calculation of the glomerular filtration rate by plasma creatinine level, fundoscopy and a number of additional methods for more detailed detection of POM, in particular echocardiography to assess left ventricular hypertrophy (LVH), ultrasonography to assess the thickness of the intima-media complex of the carotid arteries, etc.

It should be remembered about the extremely low sensitivity of the ECG method for detecting LVH. So, when using the Sokolov-Lyon index, the sensitivity is only 11%. This means a large number of false-negative results in the detection of LVH, if, with a negative ECG test result, echocardiography is not performed with the calculation of the myocardial mass index.

A classification of the stages of hypertension is proposed, taking into account the level of blood pressure, the presence of POM, concomitant diseases and the total CV risk (Table 4).

This classification allows the patient to be assessed not only by the level of blood pressure, but primarily by his total CV risk.

It is emphasized that in patients with moderate and higher risk levels, blood pressure reduction alone is not enough. Mandatory for them is the appointment of statins, which additionally reduce the risk of myocardial infarction by a third and the risk of stroke by a quarter with achieved blood pressure control. It is also noted that similar benefits have been achieved with statins in patients with lower risk. These recommendations significantly expand the indications for the use of statins in patients with hypertension.

In contrast, the indications for the use of antiplatelet drugs (primarily low doses of acetylsalicylic acid) are limited to secondary prophylaxis. Their use is recommended only for patients with diagnosed CV diseases and is not recommended for patients with hypertension without CV diseases, regardless of the total risk.

Initiation of therapy

The approaches to initiating therapy in hypertensive patients have undergone significant changes. The presence of a very high CV risk in a patient requires immediate initiation of pharmacotherapy even with high normal blood pressure (Fig. 2).

Initiation of pharmacotherapy is also recommended for elderly patients over 65 years of age, but not over 90. However, the abolition of pharmacotherapy with antihypertensive drugs is not recommended after patients reach the age of 90 years if they tolerate it well.

Target blood pressure

The change in target blood pressure levels has been actively discussed over the past 5 years and was actually initiated during the preparation of the US Joint Committee Recommendations on the Prevention, Diagnosis and Treatment of High Blood Pressure (JNC 8), which were published in 2014. The experts who prepared the JNC Guidelines 8 concluded that observational studies have shown an increase in cardiovascular risk even at a SBP ≥115 mmHg. Art., and in randomized trials using antihypertensive drugs, in fact, the benefit was proved only from reducing the SBP to values ​​≤150 mm Hg. Art. ...

To address this issue, the SPRINT study was initiated, in which 9361 high-risk CV patients with SBP ≥130 mm Hg were randomized. Art. without SD. The patients were divided into two groups, in one of which the SBP was reduced to values<120 мм рт. ст. (интенсивная терапия), а во второй – ​<140 мм рт. ст. (стандартная терапия).

As a result, the number of major CV events was 25% less in the intensive care group. SPRINT findings provide evidence for the 2017 revised US guidelines that set targets for a decrease in systolic blood pressure.<130 мм рт. ст. для всех больных АГ с установленным СС заболеванием или расчетным риском СС событий >10% in the next 10 years.

The ESH / ESC experts emphasize that in the SPRINT study, blood pressure was measured using a method that differs from traditional measurement methods, namely: the measurement was carried out at a clinic appointment, but the patient himself measured blood pressure with an automatic device.

With this method of measurement, the blood pressure level is lower than with the "office" measurement of blood pressure by a doctor by about 5-15 mm Hg. Art., which should be considered when interpreting the data from the SPRINT study. In fact, the BP level achieved in the intensive care group in the SPRINT study corresponds to approximately a SBP level of 130-140 mm Hg. Art. at the "office" measurement of blood pressure at the doctor.

In addition, the authors of the ESH / ESC Guidelines for the Management of Hypertension (2018) refer to a large, well-conducted meta-analysis that showed a significant benefit from a 10 mmHg reduction in SBP. Art. with an initial SBP 130-139 mm Hg. Art. (Table 5).

Similar results were obtained in another meta-analysis, which, in addition, showed significant benefits for lowering DBP.<80 мм рт. ст. .

Based on these studies, the ESH / ESC Guidelines for the Treatment of Hypertension (2018) set a target level of SBP reduction for all patients with hypertension.<140 мм рт. ст., что несколько отличает на первый взгляд новые европейские рекомендации от рекомендаций, принятых в 2017 году в США , которые определили для всех больных АГ целевой уровень САД <130 мм рт. ст.

However, further European experts propose an algorithm for achieving target blood pressure levels, according to which, in case of reaching the systolic blood pressure<140 мм рт. ст. и хорошей переносимости терапии следует снизить уровень САД <130 мм рт. ст. (табл. 6). Таким образом, этот алгоритм фактически устанавливает целевой уровень САД <130 мм рт. ст., однако разбивает на два этапа процесс его достижения.

In addition, a target DBP level is set.<80 мм рт. ст. независимо от СС риска и сопутствующей патологии. Следует помнить, что чрезмерное снижение уровня ДАД (критическим является уровень ДАД <60 мм рт. ст.) приводит к увеличению риска СС катастроф, что подтвердилось также и в исследовании SPRINT, и необходимо его избегать. Рекомендации ESH/ESC по лечению АГ (2018) устанавливают также целевые уровни САД для отдельных категорий больных АГ (табл. 7).

Dividing patients into groups makes some adjustments to the target SBP levels. So, in patients 65 years of age and older, it is recommended to achieve target SBP levels from 130 to<140 мм рт. ст., а у больных до 65 лет рекомендуется более жесткий контроль АД и достижение целевого САД от 120 до <130 мм рт. ст.

Also, tight control is recommended to achieve the target SBP.<130 мм рт. ст. у больных с сопутствующим СД или ишемической болезнью сердца. Достижение целевого уровня САД от 120 до <130 мм рт. ст. также рекомендовано больным после перенесенного инсульта или транзиторной ишемической атаки, однако класс рекомендации более низкий, как и уровень доказательств.

In patients with CKD, less strict blood pressure control is recommended, with the target SBP from 130 to<140 мм рт. ст. Таким образом, для большинства больных АГ рекомендован целевой уровень САД <130 мм рт. ст. при офисном измерении АД за исключением пациентов от 65 лет и старше и больных с сопутствующей ХБП, что фактически максимально приближает новые Рекомендации ESH/ESC по лечению АГ (2018) к опубликованным в 2017 году американским рекомендациям .

Achieving blood pressure control in patients remains challenging. In most cases in Europe, blood pressure is controlled in less than 50% of patients. Taking into account the new target blood pressure levels, the ineffectiveness of monotherapy in most cases and a decrease in patients' adherence to treatment in proportion to the number of pills taken, the following algorithm for achieving blood pressure control has been proposed (Fig. 3).

1. AH can be diagnosed on the basis of not only "office", but also "out-of-office" measurement of blood pressure.
2. Initiation of pharmacotherapy at high normal blood pressure in patients with very high CV risk, as well as in patients with grade 1 hypertension and low CV risk, if lifestyle changes do not lead to blood pressure control. Initiation of pharmacotherapy in elderly patients if they tolerate it well.
3. Setting a target SBP level<130 мм рт. ст. у большинства больных, достигаемого в два этапа, после снижения САД <140 мм рт. ст. и хорошей переносимости терапии.
4. A new algorithm for achieving blood pressure control in patients.

Literature

1. Williams, Mancia, et al. 2018 ESH / ESC Guidelines for the management of arterial hypertension. European Heart Journal. 2018, in press.
2. Piepoli M. F., Hoes A. W., Agewall S., Albus C., Brotons C., Catapano A. L., Cooney M. T., Corra U., Cosyns B., Deaton C., Graham I. ., Hall M. S., Hobbs F. DR, Lochen M. L., Lollgen H., Marques-Vidal P., Perk J., Prescott E., Redon J., Richter D. J., Sattar N. , Smulders Y., Tiberi M., van der Worp H. B., van Dis I., Verschuren W. MM, Binno S. ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Heart Journal. 2016. Aug 1; 37 (29): 2315-2381.
3. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014; 311 (5): 507-520.
4. The SPRINT Research Group. N. Engl. J.Med. 2015; 373: 2103-2116.
5. Whelton P. K., Carey R. M., Aronow W. S., Casey D. E. Jr., Collins K. J., Dennison Himmelfarb C., DePalma SM, Gidding S., Jamerson K. A., Jones D. W., MacLaughlin EJ, Muntner P., Ovbiagele B., Smith S. C. Jr., Spencer C. C., Stafford R. S., Taler S. J., Thomas R. J., Williams K. A. Sr., Williamson J. D., Wright J. T. Jr. 2017 ACC / AHA / AAPA / ABC / ACPM / AGS / APhA / ASH / ASPC / NMA / PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology / American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;
   71 (6): e13-e115.
6. Ettehad D., Emdin C. A., Kiran A., Anderson S. G., Callender T., Emberson J., Chalmers J., Rodgers A., Rahimi K. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016. Mar 5; 387 (10022): 957-967.
7. Thomopoulos C., Parati G., Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels - updated overview and meta-analyzes of randomized trials. J. Hypertens. 2016. Apr; 34 (4): 613-22

Currently, arterial hypertension is the leading risk factor for the development of diseases such as myocardial infarction and stroke, which mainly determine the high mortality rates in the Russian Federation. Despite the fact that about 85% of patients are aware of their disease, only 68% take drugs, only 25% are effectively treated, and only 20% of patients control target blood pressure figures. This is what accounts for the widespread prevalence of the disease. In 2018, the World Health Organization plans to revise the control indicators of blood pressure and their correspondence to the severity of hypertension: if now the first degree of hypertension starts from 140-159 and 90-99 mm Hg, the WHO recommends reducing these values ​​to 130 -139 and 85-89 mm Hg

Definition

Hypertension is a chronic disease of the cardiovascular system, the main symptom of which is systematic arterial hypertension, which is not associated with the presence of pathological processes in other organs. Normal threshold values ​​of blood pressure are 120 - 129 and / or 80 - 84 mm Hg, and at the moment the concept of office hypertension is also distinguished - measurement of blood pressure at home with an indicator of 130 and 85 mm Hg.

In the mechanism of increasing blood pressure, two groups of causes and factors are distinguished: neurogenic and humoral. Neurogenic influences through the sympathetic nervous system, affecting the tone of arterioles, and humoral ones are associated with an increased release of biologically active substances that have a pressor effect.

Classification

The blood pressure classification presented at the moment is used for persons over 18 years of age:

• The optimal blood pressure is less than 120 and 80 mm Hg.
• Normal blood pressure 120 - 129 and / or 80 - 84 mm Hg.
• High normal blood pressure 130 - 139 and / or 85 - 89 mm Hg
• 1 degree AH HELL 140 - 159 and / or 90 - 99 mm Hg
• 2 degree AH HELL 160 - 179 and / or 100 - 109 mm Hg.
• 3 degree of AH HELL more than 180 and / or 110 mm Hg.
• Isolated systolic hypertension blood pressure more than 140 and less than 90 mm Hg.

In situations where systolic and diastolic pressure do not belong to the same category, the degree is set at a higher value. Symptomatic arterial hypertension (secondary) is also distinguished.

Advice! The diagnosis can be made only after two measurements of the pressure on each arm with an interval of 5 minutes, with the exclusion of factors that increase blood pressure, at least 30 minutes before the study.

It should be noted that the parameters of high blood pressure are rather arbitrary, since there is a direct relationship between the level of blood pressure and the risk of cardiovascular diseases, starting with indicators of 115 and 75 mm Hg. To assess the level of pressure on each arm, at least two measurements with a break of 1 minute are required. When there is a difference in indicators of more than 5 mm Hg. additional measurement is required. The final result is the minimum of the three. For the correct determination of the results, it is necessary to comply with certain conditions of the determination, namely:

1. Exclude coffee, tea, alcohol one hour before the study;
2. Quitting smoking in 30 minutes;
3. Cancellation of drugs - sympathomimetics, including eye and nasal drops;
4. Lack of physical and emotional stress.

The blood pressure is measured after a five minute rest. The patient sits on a chair in a comfortable position, the legs are not crossed, the hand is at the level of the heart and lies on the table in a relaxed state.

Diagnostics

Examination and differential diagnosis for arterial hypertension includes the following studies:

• Collection of information about the history of the present disease and patient complaints. Find out information about the symptoms of damage to target organs and hereditary predisposition;
• Re-measurement of blood pressure - the diagnosis is made at high blood pressure after two measurements at two different visits.
• Physical examination includes anthropometry - measurement of waist circumference, height, body weight, body mass index calculation. Also, auscultation of the heart and great arteries is performed, the pulse is calculated on the radial arteries in order to detect arrhythmias.
• Laboratory research. At the first stage, the following analyzes are carried out: general blood and urine analysis, fasting glucose, total cholesterol, high and low density lipoproteins, triglycerides, Potassium, Sodium. According to the indications at the second stage, the measurement of creatinine clearance, glomerular filtration rate, uric acid level, protein in urine (microalbuminuria), urine according to Nechiporenko, ALT, AST, oral glucose tolerance test is carried out.
• Instrumental diagnostics includes electrocardiography with test stress tests, echocardiography to clarify the morphological parameters of myocardial damage, duplex scanning of the brachiocephalic arteries, determination of the pulse wave velocity, ankle-brachial index, ultrasound of the kidneys, examination of the fundus, chest X-ray, 24-hour blood pressure monitoring , assessment of general cardiovascular risk using specialized scales.

Treatment

The main goal of conservative therapy is to minimize the risk of complications and target organ damage as much as possible. For this purpose, blood pressure indicators are reduced to normal values, exogenous risk factors are corrected, the course and progression of target organ damage is prevented or slowed down, and existing concomitant diseases are corrected.

These measures are recommended for all patients, thereby providing primary prevention in patients with high normal blood pressure and reducing the need for drug therapy in patients with arterial hypertension. Clinical guidelines for lifestyle changes are based on the following main aspects:

• The daily restriction on the intake of table salt is up to 3-5 grams per day.
• Refusal to consume alcoholic beverages (the maximum dose of alcohol per week is 140g for men and 80g for women).
• Normalization of diet and eating behavior: fractional meals 5-6 times a day in small portions with a rational ratio of proteins, fats and carbohydrates.
• Decrease in body mass index to physiological figures.
• Increased physical activity.
• Quitting smoking tobacco products.

Drug treatment

The selection of an antihypertensive drug is carried out on an individual basis. In the modern treatment of hypertension, 5 groups of drugs are used:

1. Adenosine converting enzyme (ACE) inhibitors. Slow down the development and progression of target organs, for example, left ventricular hypertrophy of the myocardium, proteinuria, reduces microalbuminuria and slows down the decrease in the filtration function of the kidneys;
2. Angiotensin 2 receptor blockers. It is most effective in patients with increased activity of the renin-angiotensin-aldesterone system. The number of side effects is reduced in comparison with ACE inhibitors, but the effect is milder and less pronounced;
3. Calcium channel blockers. They slow down the intracellular calcium flow in peripheral vessels, thereby reducing the sensitivity of the vessels to amines. There are two groups of CCBs: dihydroperidines and nondihydroperidines. The former have a pronounced selective effect on vascular smooth muscles, do not cause a decrease in the contractile function of the myocardium. Non-dihydroperidines have an inotropic and dromotropic effect on the heart muscle;
4. Beta-blockers - reduce the frequency and strength of heart contractions, as well as the secretion of renin, thereby weakening the load on the heart;
5. Diuretics They reduce the volume of circulating blood and minute volumetric blood flow, which lowers the preload on the heart and reduces the severity of arterial hypertension.

Each of these groups of drugs has its own indications and contraindications, can be used as monotherapy, and as part of complex drug treatment.

Important! Do not try to combine drugs on your own, as this can cause a number of side effects. To correctly identify the cause of the disease and prescribe drugs, consult your doctor.

The most rational combinations are ACE inhibitors + diuretic; Beta blockers + diuretic; calcium antagonist + beta blocker.

Irrational combinations that lead to increased side effects of drugs include a combination of drugs of the same class, as well as the following combinations: ACE inhibitors + Potassium-sparing diuretic; beta-blocker + non-dihydroperidine calcium antagonist.

In some cases, drugs of other groups can be prescribed in the presence of somatic pathology, for example, antiplatelet agents, anticoagulants and statins.

In some cases, surgical treatment may be recommended, if the main components of therapy are ineffective or in advanced cases with damage to target organs. It is recommended to perform radiofrequency denervation of the renal arteries, which leads to a stable decrease in office blood pressure.

Conclusion

Thus, arterial hypertension is one of the most common pathological conditions among the population. There is a need to periodically monitor the blood pressure numbers, as well as regularly visit a therapist and, if there is a risk of hypertension or already formed hypertension, follow the recommendations of the attending physician on taking medications and monitoring blood pressure, as well as being monitored by a cardiologist.

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Arterial hypertension (AH) is the most important modifiable cardiovascular risk factor. It is generally recognized that high blood pressure (BP) is associated with an increased risk of fatal and non-fatal myocardial infarction and cerebral strokes, as well as with an accelerated progression of chronic kidney disease.

This report briefly discusses the current understanding of the classification, diagnosis, and treatment of hypertension. For this, we used a number of materials published in 2013-2014. documents, including: 1) Recommendations of the European Society of Hypertension and the European Society of Cardiology (ESH / ESC) for the treatment of hypertension, 2013; 2) American Society of Hypertension and International Society of Hypertension (ASH / ISH) Clinical Guidelines for the Treatment of Hypertension, 2013); 3) Eighth Recommendations of the US Joint National Committee on the Management of High Blood Pressure in Adults (JNC-8).

Definition. The term AG denotes a condition in which there is sustained increase in blood pressure levels: systolic blood pressure ≥ 140 mm Hg. and / or diastolic blood pressure ≥ 90 mm Hg. The classification of blood pressure levels and degrees of hypertension is presented in table 1.

Table 1. Classification of blood pressure levels (mm Hg) and degrees of hypertension

Allocate primary hypertension (the term "essential AG" is also used, we have a generally accepted designation "hypertonic disease" ), in which the increase in blood pressure is not directly associated with any organ damage, and secondary (or "symptomatic") hypertension , in which AH is associated with lesions of various organs / tissues (Table 2).

Among all persons with hypertension, the proportion of patients with essential hypertension is about 90%; the share of all symptomatic hypertension listed in Table 2 in total accounts for about 10%. Among symptomatic hypertension, the most common are renal (up to half of cases of symptomatic hypertension).

Table 2. Classification of hypertension by etiology

Primary hypertension (essential hypertension, essential hypertension)
Secondary hypertension (symptomatic):
Renal: 1. Renoparenchymal 2. Renovascular 3. AH in renin-producing tumors 4. Renoprivna hypertension (after nephrectomy)	Endocrine: Adrenal (for disorders in the cortical layer - Cushing's syndrome, for disorders in the medullary layer - pheochromocytoma) Thyroid (with hyper- or hypothyroidism) Hypertension with acromegaly, hyperparathyroidism, carcinoid Hypertension while taking exogenous hormonal drugs (estrogens, gluco- and mineralocorticoids, sympathomimetics)
AH in coarctation of the aorta	Hypertension due to pregnancy
Hypertension associated with neurological causes (for inflammatory and tumor lesions of the central nervous system)	Hypertension due to increased cardiac output (for example, isolated systolic hypertension with increased stiffness of the aortic wall in the elderly, hypertension with aortic valve insufficiency, hypertension with an arteriovenous fistula)

Classification of hypertension according to the degree of cardiovascular risk

The standard is now highlighting (and indicating when formulating a diagnosis) degrees of additional cardiovascular risk in hypertension (Table 3); For this, it is customary to take into account the presence of cardiovascular risk factors, lesions of target organs and concomitant diseases in the patient along with hypertension (Table 4).

Table 3. Levels of additional cardiovascular risk in hypertension

AG + (FR, POM, SZ)	Normal -120-129 / 80-84 mm Hg	High normal - 130-139 / 85-89	AG 1 degree - 140-159 / 90-99	AG 2 degrees - 160-179 / 100-109	AH grade 3 - ≥180 / ≥110
	Average risk in the population	Average risk in the population	Low additional risk		additional risk
	Low additional risk	Low additional risk	Moderate additional risk	Moderate additional risk
≥3 FR or SD, POM	Moderate additional risk	High additional risk	High additional risk	High additional risk	Very high additional risk
	Very high additional risk	Very high additional risk	Very high additional risk	Very high additional risk	Very high additional risk

Notes: RF - risk factors, POM - target organ damage, СЗ - concomitant diseases, DM - diabetes mellitus (see Table 4). According to the Framingham Criteria, the terms "low", "medium", "high" and "very high" risk mean a 10-year chance of developing cardiovascular complications (fatal and non-fatal)<15%, 15-20%, 20-30% и >30%, respectively.

Table 4. Cardiovascular risk factors, target organ damage and comorbidities in hypertension

Cardiovascular risk factors: Age (M ≥ 55, W ≥ 65 years) Smoking Dyslipidemia (total cholesterol> 4.9 mmol / L or LDL cholesterol> 3.0 mmol / L or HDL cholesterol<1,0 (М) и <1,2 ммоль/л (Ж) или ТГ >1.7 mmol / L) Fasting plasma glucose ≥ than 2 dimensions 5.6-6.9 mmol / L Impaired glucose tolerance Obesity (body mass index ≥ 30 kg / m2) Abdominal obesity (waist circumference ≥102 cm (M) and ≥88 cm (W) Cardiovascular diseases in relatives under 55 (M) / 65 (F)

Target organ damage: High pulse blood pressure in the elderly (≥ 60 mm Hg) LV hypertrophy - according to ECG * (Sokolov-Lyon index> 3.5 mV or Cornell product> 2440 mm x ms) or according to echocardiogram data ** (LV myocardial mass index ≥ 115 g / m2 (M) / ≥ 95 g / m 2 (W)) Thickening of the carotid artery wall (intima-media complex thickness> 0.9mm) or plaque Pulse wave velocity *** (on carotid - femoral arteries)> 10 m / s Ankle-brachial index ****< 0,9 Glomerular filtration rate (GFR) 30-60 ml / min / 1.73m 2 Microalbuminuria 30-300 mg / day or mg / ml

Accompanying illnesses: Postponed strokes, transient ischemic attacks · Cardiac ischemia Chronic heart failure with reduced systolic function of the left ventricle, as well as with its intact ejection fraction Chronic kidney disease (GFR<30 мл/мин/1,73м 2 ; протеинурия >300 mg / day) Symptomatic peripheral arterial disease Severe retinopathy (hemorrhages, exudates, edema)

Diabetes: · Diagnostics: glycosylated hemoglobin ≥ 7.0% or fasting plasma glucose (not eating for ≥ 8 hours) 2 times ≥7.0 mmol / L or glucose 2 hours after glucose load (75 g glucose) ≥11.1 mmol / L

Notes: CS - cholesterol; LDL - low density lipoprotein; HDL - high density lipoprotein; TG - triglycerides; ECG - electrocardiogram; LV - left ventricle; GFR is the glomerular filtration rate.

* - ECG - diagnosis of LV hypertrophy ... Sokolov-Lyon index: SV1 + (RV5 or RV6); Cornell product in men: (RavL + SV3) x QRS (ms), in women: (RavL + SV3 +8) x QRS (ms).

** –Echocardiographic diagnosis of LV hypertrophy. For this, the American Society of Echocardiography - ASE formula is now widely used, in which the mass of the LV myocardium is (LVMM) = 0.8 x (1.04 x (LV ECD + LVWD + LVWD) 3 - (LV EDS) 3)) + 0.6 , where LV ED is the end-diastolic size of the LV; TZSLZH - thickness of the posterior wall of the LV in diastole; TMZhP - the thickness of the interventricular septum in diastole. To calculate the LVMM index, the value of LVMM obtained using this formula is divided by the patient's body surface area (the table shows the normal values ​​of the LVMM index for this calculation option). Some experts consider it more acceptable to index LVMM not on the body surface area, but on the patient's height to the degree of 2.7 (height 2.7) or growth to the degree of 1.7 (height 1.7) - to improve the identification of LV hypertrophy in overweight individuals body or obese.

*** – Pulse wave velocity is assessed using mechanical or Doppler recording of a pulse wave on the carotid and femoral arteries.

**** –Ankle-brachial index - the ratio of systolic blood pressure at the ankle (cuff - on the distal leg) to systolic blood pressure at the shoulder.

Figure 1 shows a variant of the SCORE scale recommended by European experts in order to assess the level of cardiovascular risk for countries with an initially high population level of such risk (including Kazakhstan). For the correct use of the scale, you should find the cell corresponding to those indicators of gender, age, systolic blood pressure and total cholesterol that a particular patient has. The number in the box represents the approximate 10-year risk of death from cardiovascular causes (expressed as a percentage). According to the SCORE scale, the following categories of 10-year risk of death from cardiovascular causes are distinguished: very high (≥ 10%), high (5-9%), moderate (1-4%) and low (0%).

Figure 1. Systematic COronary Risk Evaluation (SCORE), assessing the 10-year risk of death from cardiovascular disease depending on gender, age, smoking, blood pressure and total serum cholesterol levels (option recommended by ESC experts for countries, with a high level of cardiovascular risk in the population, including for Kazakhstan) - suitable for people of the general population without heart disease and diabetes mellitus, aged ≥ 40 years *

Notes: Cholesterol - total cholesterol; * - there are more complex versions of the scale, which also take into account the levels of LDL cholesterol and HDL cholesterol; all scale options and electronic calculators are available online - see www.escardio.org

Epidemiology

Hypertension is one of the most common chronic diseases. Hypertension is the most common chronic disease in the practice of a primary care physician (general practitioner - family doctor). Hypertension occurs in about one third of the population of most developed and developing countries. When analyzing the structure of AH by blood pressure levels, approximately 1/2 has AH of 1 degree, 1/3 - 2 degrees and 1/6 - 3 degrees. The prevalence of hypertension increases with age; at least 60% of people aged> 60-65 years have high blood pressure or are receiving antihypertensive therapy. Among people aged 55-65 years, the likelihood of developing hypertension, according to the Framingham study, is more than 90%.

The World Health Organization considers hypertension as the most important potentially preventable cause of death in the world .

AH is associated with increased cardiovascular mortality and increased risk of cardiovascular complications in all age groups; among the elderly, the degree of this risk has a direct relationship with the level of systolic blood pressure (SBP) and an inverse relationship with the level of diastolic blood pressure (DBP).

There is also an independent relationship between the presence of hypertension, on the one hand, and the risk of heart failure, peripheral arterial lesions, and decreased renal function, on the other.

According to epidemiological data, in Western countries, about 50% of hypertensive patients are not aware of their high blood pressure (i.e. they have not been diagnosed with hypertension); among people with hypertension, only about 10% have blood pressure control within the target values.

Isolated systolic hypertension (ISAG) in the elderly

A number of world experts consider it as a separate pathological condition inherent in the elderly, associated with a decrease in the compliance of the arterial wall; with ISAG increased SBP and decreased DBP (Table 1). An increase in SBP is an important pathophysiological factor contributing to the development of left ventricular hypertrophy; a decrease in DBP can lead to a deterioration in coronary blood flow. The prevalence of ISAG increases with age; in the elderly, it is the most common form of hypertension (up to 80-90% of all cases of hypertension).

In the elderly the presence of ISAH is associated with a more significant increase in the degree of cardiovascular risk than the presence of systolic-diastolic hypertension (with comparable values ​​of SBP).

To assess the degree of additional cardiovascular risk in ISAH, the same SBP levels, the same designations of risk factors, target organ damage and concomitant diseases should be used as in systolic-diastolic hypertension (Tables 1, 3, 4). It should be borne in mind that especially low levels of DBP (60-70 mmHg and below) are associated with an additional increase in risk .

"AG white coat" ("AG in the doctor's office", "office AG")

Diagnosed if blood pressure measured at the doctor's office is ≥140 / 90 mmHg. in at least 3 cases, with normal values ​​of blood pressure at home and according to the data of outpatient monitoring of blood pressure (AMAD - see "Diagnosis of hypertension"). White coat hypertension is more common in the elderly and in women. It is believed that the cardiovascular risk in these patients is lower than in patients with persistent hypertension (i.e., with blood pressure levels that are higher than normal when measured at home and with AMP), but probably higher than in normotensive individuals. Such individuals are advised to make lifestyle changes, and in the case of high cardiovascular risk and / or target organ damage, drug therapy (see section “Treatment of hypertension”).

Diagnosis of hypertension

BP levels are characterized by spontaneous variability during the day, as well as for longer periods of time (weeks-months).

The diagnosis of hypertension should usually be based on repeated blood pressure measurements. performed under various circumstances; the standard statement of the AG is provided according to the data at least 2-3 visits to the doctor (during each visit, the blood pressure must be increased for at least 2 measurements) .

If at the first visit to the doctor, blood pressure is only moderately elevated , then a re-assessment of blood pressure should be performed after a relatively longer period - after a few months (if the blood pressure level corresponds to grade 1 of hypertension - Table 1 and there are no target organ lesions).

When, if at the first visit the blood pressure level is increased more significantly (corresponds to the 2nd degree of AH - Table 1) , or if there are possibly hypertension-related target organ lesions, or if the level of additional cardiovascular risk is high, then a reassessment of blood pressure should be done after a relatively shorter time interval (weeks-days); if the level of blood pressure at the first visit corresponds to grade 3 of hypertension if there is a clear symptomatology of hypertension, the level of additional cardiovascular risk is high, then the diagnosis of hypertension can be based on data obtained during a single visit to the doctor.

Blood pressure measurement

Blood pressure measurement is recommended as standard. mercury sphygmomanometer or aneroid manometer (the latter have become widespread due to the trend towards the elimination of mercury from widespread use). Regardless of the type, devices for measuring blood pressure must be serviceable , their indicators should be periodically checked (when compared with the data of other devices, usually mercury sphygmomanometers).

It is also possible to use semi-automatic devices for measuring blood pressure ; the accuracy of their work should be established according to standard protocols; blood pressure readings should be periodically checked against data from mercury sphygmomanometers.

When measuring blood pressure, you should adhere to the following rules: · Provide the patient with the opportunity to sit for 3-5 minutes in a calm environment before measuring blood pressure. The patient's legs should be off-weight. In a sitting position, at least two measurements of blood pressure must be taken, with a break between them lasting 1-2 minutes. If the obtained values ​​differ greatly (> 10 mm Hg) - measure the blood pressure a third time. The average value of the measurements should be taken into account. · In individuals with arrhythmias (eg, atrial fibrillation), BP should be measured several times to improve the accuracy of the BP estimate. · Typically a standard size air cuff (12-13 cm wide x 35 cm long) should be used. However, when measuring blood pressure in persons with a larger (> 32 cm) or smaller than usual shoulder circumference, it is necessary to use cuffs of greater or lesser length, respectively. · Regardless of the position of the patient's body, the manometer should be located at the level of the heart. · When using the auscultatory measurement method, I (the first appearance of a clear tapping sound) and V (the disappearance of a tapping sound) Korotkoff tones are used to assess the systolic and diastolic blood pressure, respectively. · At the first visit of the patient, blood pressure should be measured on both arms. The higher of the obtained values ​​should be taken into account. · * If the difference in blood pressure levels on the two arms is> 20 mm Hg, then you need to measure the blood pressure on the two arms again. While maintaining the difference in blood pressure values> 20 mm Hg. during re-measurement, subsequent blood pressure measurements should be taken on the arm where the blood pressure levels were higher. In the elderly, in patients with diabetes mellitus, as well as in other situations when orthostatic hypotension can be assumed, blood pressure should be measured 1 and 3 minutes after standing up (with caution!). The presence of orthostatic hypotension (defined as a decrease in systolic blood pressure by ≥ 20 mm Hg or in diastolic blood pressure by ≥ 10 mm Hg 3 minutes after standing up) has been shown to be an independent cardiovascular risk factor. · After the second measurement of blood pressure, the pulse rate should be estimated (by palpation, within 30 seconds).

Ambulatory blood pressure monitoring ( AMAD) compared with conventional blood pressure control. AMAD allows you to avoid possible measurement inaccuracies associated with a violation of its methodology, malfunctioning of the apparatus, and anxiety of the patient. This method also provides the ability to obtain multiple measurements of blood pressure over a 24-hour period without affecting the emotional status of the patient. It is considered to be more reproducible than episodic measurement. AMAD data are less affected by the “white coat effect”.

The blood pressure levels recorded with AMAD are usually lower than those detected when measured in the doctor's office (Tables 6, 7).

Table 6. Determination of hypertension according to the measurement of blood pressure in the doctor's office and outside the doctor's office

Indications for AMAD include: 1) the unclear diagnosis of hypertension, the assumption of the presence of the "white coat effect"; 2) the need to assess the blood pressure response to treatment, especially if the measurement data in the doctor's office consistently exceed the target blood pressure levels; 3) significant variability in the data obtained when measuring blood pressure in the doctor's office; 4) the assumption of the presence of hypertension resistance to treatment; 5) the assumption of the presence of episodes of hypotension.

Table 7. Principles of AMAD

· AMAD is one of the most important research methods in persons who are expected to have hypertension (for its diagnosis), as well as in those who have been diagnosed with hypertension (to assess the characteristics of hypertension and treatment tactics). · AMAD allows you to avoid possible measurement inaccuracies associated with a violation of his methodology, malfunction of the device, anxiety of the patient; considered to be more reproducible than episodic measurement; less affected by the "white coat effect". · AMAD is performed using portable devices. The cuff is usually placed over the shoulder of the non-dominant arm. The duration of AMAD is 24-25 hours (covers the periods of wakefulness and sleep) · The initial blood pressure level measured by the AMAD device should not differ from that previously measured with a conventional manometer by more than 5 mm Hg. Otherwise, the AMAD cuff should be removed and put on again. · The patient is instructed to adhere to his usual routine of activity, but refrain from excessive exertion. During the period of air injection into the cuff, it is recommended to refrain from movement and conversation, to keep the shoulder as still as possible and at the level of the heart. · During AMAD, the patient should keep a diary in which to reflect the time of taking medications, eating, waking up and falling asleep, and also note any symptoms that may be associated with a change in blood pressure. With AMAD, blood pressure measurements are usually taken every 15 minutes during the day and every 30 minutes at night (other options are possible, for example, every 20 minutes, regardless of the time of day). Significant gaps in measurements should be avoided. With computer analysis, at least 70% of all measurements must be of adequate quality. · When interpreting the results of AMAD, first of all, the data of the average daily, average daily and average nighttime blood pressure should be taken into account. The data of measurements of blood pressure for shorter periods of time, as well as more complex indicators (ratios, indices), are of less importance. · It is important to assess the ratio of average night / average daily blood pressure. Normally, blood pressure decreases at night; persons with such a decrease ("dipping") are designated as "dippers" (with levels of this ratio in the range of 0.8-0.9). Those who do not show a physiological decrease in blood pressure at night (with a ratio> 1.0 or, to a lesser extent, 0.9-1.0), show a higher incidence of cardiovascular complications compared with those who have an adequate nightly decrease in blood pressure. Some authors also distinguish a category of people with excessive nocturnal decrease in blood pressure (ratio ≤ 0.8), however, the prognostic significance of this phenomenon needs to be clarified.

Home blood pressure monitoring (MADD): advantages and modern concepts (table 8) . This method is becoming more and more common, especially with the expansion of the use of semi-automatic devices for measuring blood pressure.

Table 8. Principles of MADD

· The data obtained with MADD are of great importance for the diagnosis of hypertension (Table 6), assessment of its features and prognosis. Thus, MADD results correlate better with target organ damage, as well as with cardiovascular prognosis, than blood pressure levels obtained when measured in the doctor's office. The data show that with the correct performance of MADD, its results have the same high predictive value as the data of AMAD. · BP should be measured daily for at least 3-4 consecutive days (preferably within 7 consecutive days) - in the morning and in the evening. Blood pressure is measured in a quiet room, after 5 minutes of rest, in the sitting position of the patient (the back and shoulder on which blood pressure is measured must be supported). · 2 blood pressure measurements are performed with a break between them for 1-2 minutes. · Record the results in a standard form immediately after measurement. · The result of MADD is the average data of all measurements, except for the readings obtained on the 1st day. · It is up to the doctor to interpret the results of the MADD. · Most patients with hypertension (in the absence of cognitive impairment and physical limitations) should be trained in the method of self-monitoring of blood pressure. Self-monitoring of blood pressure may not be indicated in persons with excessive anxiety and phobias (where AMAD is more preferable), with a very large shoulder circumference, with significant irregularity of the pulse (for example, with atrial fibrillation), with a very pronounced increase in the rigidity of the vascular wall (all available for for measuring blood pressure, portable semiautomatic devices use the oscillometric method, which can cause distortion of the results in such patients).

Examination of patients with hypertension

Examination of patients with hypertension (including the collection of anamnesis - table 9, parts 1 and 2; objective research - table 10; as well as laboratory and instrumental studies - table 11) should be aimed at finding:

• factors provoking hypertension;
• target organ damage;
• data on the presence of symptomatic hypertension;
• clinical manifestations of cardiovascular complications (chronic heart failure, cerebrovascular and peripheral vascular complications, etc.);
• comorbidities / conditions (diabetes mellitus, atrial fibrillation, impaired cognitive function, frequent falls, unsteadiness when walking, etc.) that can affect the choice of treatment tactics.

Table 9. Features of taking anamnesis in patients with hypertension (part 1)

Determining the period of time during which the patient knows about an increase in blood pressure (including according to self-measurement data)

Search for possible causes of symptomatic hypertension: 1. Family history of CKD (eg, polycystic kidney disease) 2. Anamnesis data on the presence of CKD (including episodes of dysuria, macrohematuria), on the abuse of analgesics, NSAIDs 3. Taking medications that can increase blood pressure (oral contraceptives, vasoconstrictor nasal drops, gluco- and mineralocorticoids, NSAIDs, erythropoietin, cyclosporin) 4. Taking amphetamines, caffeine, licorice (licorice) 5. Episodes of sweating, headaches, anxiety, palpitations (pheochromocytoma) 6. Episodes of muscle weakness and seizures (hyperaldosteronism) 7. Symptoms suggestive of thyroid dysfunction

Assessment of cardiovascular risk factors: 1. Individual or family history of hypertension, cardiovascular disease, dyslipidemia, diabetes mellitus (polyuria, glucose levels, antihyperglycemic drugs) 2. Smoking 3. Diet habits (table salt, liquid) 4. Body weight, its recent dynamics. Obesity 5. The amount of physical activity 6. Snoring, breathing disorders during sleep (including from the words of a partner) 7. Low birth weight 8. For women - postponed preeclampsia during pregnancy

Note: NSAIDs - non-steroidal anti-inflammatory drugs

Table 9. Features of taking anamnesis in patients with hypertension (part 2)

Target Organ Damage Data and cardiovascular diseases: 1. Brain and eyes: headache, dizziness, visual disturbances, movement disorders, sensory disturbances, transient ischemic attacks / strokes, carotid revascularization procedures. 2. Heart: chest pain, shortness of breath, edema, syncope, palpitations, rhythm disturbances (especially atrial fibrillation), myocardial infarction, coronary revascularization procedures. 3. Kidneys: thirst, polyuria, nocturia, macrohematuria. 4. Peripheral arteries: coldness of the extremities, intermittent claudication, painless walking distance, postponed peripheral revascularization procedures. 5. Snoring / chronic lung disease / sleep apnea. 6. Cognitive dysfunction.

Data on the treatment of hypertension: 1. Currently antihypertensive drugs. 2. Antihypertensive drugs in the past. 3. Data on adherence and non-adherence to treatment. 4. The effectiveness and side effects of drugs.

Table 10. Features of objective research in patients with hypertension
(search for symptomatic hypertension, target organ damage, obesity)

Search for symptomatic hypertension: 1. Identification of features typical for Cushing's syndrome during examination. 2. Skin signs of neurofibromatosis (pheochromocytoma). 3. Palpation of enlarged kidneys (polycystic). 4. At auscultation of the abdomen - murmurs over the projections of the renal arteries (renovascular hypertension). 5. At auscultation of the heart and projections of large vessels - noises characteristic of coarctation of the aorta, other lesions of the aorta (dissection, aneurysms), lesions of the arteries of the upper extremities. 6. Weakening of the pulse and lowering the pressure on the femoral arteries in comparison with that on the brachial arteries (coarctation of the aorta, other lesions of the aorta (dissection, aneurysms), lesions of the arteries of the lower extremities). 7. Significant difference in blood pressure levels measured on the right and left brachial arteries -> 20 mm Hg. systolic blood pressure and / or> 10 mm Hg. diastolic blood pressure (coarctation of the aorta, stenosis of the subclavian artery).

Search for target organ lesions: 1. Brain: movement disorders, sensitivity disorders. 2. Retina: disorders in the fundus. 3. Heart: heart rate, apical impulse, limits of relative cardiac dullness, 3rd and 4th heart sounds, murmurs, rhythm disturbances, wheezing in the lungs, peripheral edema. 4. Peripheral arteries: absence, decrease or asymmetry of the pulse, cold extremities, ischemic skin changes. 5. Carotid arteries: systolic murmurs.

Obesity assessment: 1. Height and weight. 2. Calculation of body mass index: weight / height 2 (kg / m 2). 3. Waist circumference is measured in a standing position midway between the lower edge of the costal arch and the iliac crest.

Table 11. Laboratory and instrumental studies in hypertension

Routine examinations:
1. Complete blood count 2. Fasting plasma glucose 3. Total cholesterol, serum low and high density lipoproteins 4. Serum triglycerides	5. Serum sodium and potassium 6. Serum uric acid 7. Serum creatinine, calculation of the glomerular filtration rate 8. Analysis of urine, test for microalbuminuria 9. 12-lead ECG
Additional studies (taking into account data from anamnesis, objective research and the results of routine research):
1. Glycosylated hemoglobin (if plasma glucose is> 5.6 mmol / L and in persons with diabetes mellitus) 2. Sodium and potassium urine 3. AMAD and MADD 4. Echocardiography 5. Holter ECG monitoring 6. Exercise tests to detect coronary ischemia	7. Ultrasound examination of the carotid arteries 8. Ultrasound examination of peripheral arteries, abdominal organs 9. Estimation of the speed of propagation of the pulse wave 10. Determination of the ankle-brachial index 11. Examination of the fundus
Research conducted under conditions specialized assistance:
1. Further search for brain, cardiac, renal and vascular lesions (with resistant and complicated hypertension) 2. Search for the causes of symptomatic hypertension, which are assumed taking into account data from anamnesis, objective research and previous examinations

Hypertension treatment

Beneficial effects of blood pressure control within target levels in persons with hypertension (according to RCTs and meta-analyzes).

A decrease in cardiovascular mortality and the incidence of cardiovascular complications has been shown, as well as a less pronounced effect on overall mortality. There is also a clear decrease in the risk of developing chronic heart failure.

The reduction in the risk of stroke with antihypertensive therapy is more pronounced than the reduction in the risk of coronary complications. Thus, a decrease in diastolic blood pressure by only 5-6 mm Hg. leads to a decrease in the risk of stroke within 5 years by about 40%, and coronary heart disease by about 15%.

The more pronounced the degree of blood pressure reduction (within the target levels), the higher the beneficial effect on the prognosis.

The listed beneficial effects are also shown in the elderly, incl. with isolated systolic hypertension. Favorable effects were noted in patients of different ethnic groups (in white-skinned, black, Asian populations, etc.).

The goals of hypertension treatment. The main goal of hypertension treatment is reducing cardiovascular risk, reducing the risk of developing CHF and chronic renal failure ... The beneficial effects of treatment must be weighed against the risk associated with possible complications of treatment. In the treatment tactics, it is important to provide measures aimed at correcting the potentially corrective factors of cardiovascular risk identified in the patient, including smoking, dyslipidemia, abdominal obesity, and diabetes mellitus.

Target blood pressure levels recommended by experts from Europe and the United States in the course of antihypertensive therapy are presented in table. 12. For the category of elderly patients with hypertension, it is important to keep in mind that their blood pressure levels usually vary more significantly; that they are more likely to develop episodes of hypotension (including orthostatic, postural hypotension). The choice of the target blood pressure level for a particular patient should be individual.

Table 12. Target blood pressure levels for hypertensive patients

	Target blood pressure,
Uncomplicated hypertension
Hypertension in combination with coronary artery disease (including postinfarction)
Hypertension after stroke
Hypertension in combination with lesions of peripheral arteries
AH in combination with CKD (with proteinuria< 0,15 г/л)
AH in combination with CKD (with proteinuria ≥ 0.15 g / l)
Hypertension in combination with type 1 and 2 diabetes mellitus
Hypertension in pregnant women
AH in patients aged 65 and over	Systolic 140 - 150
Hypertension in frail elderly people	At the discretion of the doctor

Note. * - at low levels of "evidence base".

Non-pharmacological treatment

The following lifestyle changes help lower blood pressure and reduce cardiovascular risk:

• Weight Loss for Obese Patients (if the body mass index is more than 30 kg / m 2). It has been shown that in such patients a persistent decrease in body weight by 1 kg is accompanied by a decrease in systolic blood pressure by 1.5-3 mm Hg, diastolic blood pressure by 1-2 mm Hg.
• Regular outdoor exercise (for a hemodynamically stable patient - at least 150 (or better - at least 300) minutes per week; in many patients, walking quickly enough for 30-45 minutes daily or at least 5 times a week). Isometric loads (for example, lifting weights) contribute to an increase in blood pressure, it is desirable to exclude them.
• Reducing the consumption of table salt ... It has been shown that a decrease in salt intake to 5.0 g / day (this amount is contained in 1/2 teaspoon) is associated with a decrease in systolic blood pressure by 4-6 mm Hg, diastolic blood pressure - by 2-3 mm Hg. ... A decrease in blood pressure due to a decrease in salt intake is more pronounced in the elderly. As a fairly effective measure (which helps to reduce salt intake by about 30%), the recommendation to remove the salt shaker from the table can be used.
• Reducing alcohol intake.
• Reducing your intake of saturated fat (animal fats).
• Increasing your intake of fresh fruits and vegetables (in total, preferably about 300 g / day),
• Smoking cessation .

Pharmacological treatment

Pharmacological treatment (Table 13) required by most patients with hypertension , the main goal of this treatment is to improve the cardiovascular prognosis.

Table 13. General questions of pharmacological treatment in hypertension

Drug therapy for hypertension (in combination with non-drug therapeutic approaches) with sustained maintenance of blood pressure levels within the target values ​​contributes to a significant improving cardiovascular (with a decrease in the risk of developing fatal and non-fatal cerebral strokes and myocardial infarctions), and renal prognosis (with a decrease in the rate of progression of renal lesions).

Treatment (non-drug and medication) should be started as early as possible and carried out continuously, usually throughout life. The concept of “course treatment” is not applicable to antihypertensive therapy.

· Elderly patients with hypertension are advised to start antihypertensive drug therapy at systolic blood pressure levels ≥ 160 mm Hg. (I / A). Antihypertensive drugs can be given to the elderly under 80 years of age and systolic blood pressure levels in the 140-159 mmHg range if well tolerated (IIb / C) Antihypertensive therapy is not recommended until further evidence is available. people with high normal blood pressure - 130-139 / 85-89 mm Hg (III / A). This recommendation primarily applies to individuals who do not have concomitant cardiovascular lesions.

In the treatment of patients with hypertension, the most commonly used 5 classes of antihypertensive drugs : diuretics, calcium channel blockers, ACE inhibitors, sartans, beta-blockers. For these classes of drugs, there are large studies demonstrating their beneficial effects on prognosis. Other classes of antihypertensive drugs (referred to as "second line") may also be used.

Widespread is (helps to improve the effectiveness and safety of treatment). Justified use fixed combination drugs (improves the "adherence" of the patient).

Antihypertensive drugs are preferred extended action ( incl. retard forms).

After the appointment of antihypertensive therapy, the doctor should examine the patient. no later than 2 weeks ... In case of insufficient decrease in blood pressure, you should increase the dose of the drug, or change the drug, or additionally prescribe a drug of a different pharmacological class. In the future, the patient should examine regularly (every 1 to 2 weeks) until satisfactory blood pressure control is achieved ... After stabilization of blood pressure, the patient should be examined every 3-6 months (with a satisfactory state of health).

Shown, that the use of antihypertensive drugs in hypertensive patients under the age of 80 and ≥80 years is accompanied by an improvement in the cardiovascular prognosis. Adequate pharmacological treatment of hypertension does not adversely affect cognitive function in elderly patients, does not increase the risk of developing dementia; moreover, it is likely to reduce this risk.

Treatment must begin with small doses , which can be gradually increased if necessary. The choice of drugs with daily duration of action .

Tables 14-17 show the classifications of the different classes of antihypertensive drugs; the place of the sartans is discussed in more detail below.

Table 14. Diuretics in the treatment of hypertension (adapted from ISH / ASH, 2013)

Name	Doses (mg / day)		Multiplicity of reception
Thiazide:
Hydrochlorothiazide *
Bendroflumethiazide
Thiazide-like:
Indapamide
Chlorthalidone
Metolazone
Loopback:
Furosemide	20 mg 1 p / day	40 mg 2 r / day #
Torasemid
Bumetanide
Potassium-sparing:
Spironolactone **
Eplerenone **
Amiloride
Triamteren

Notes: * - part of the fixed combination of telmisartan with hydrochlorothiazide; ** - refer to mineralocorticoid receptor antagonists (aldosterone antagonists); # - with reduced kidney function, higher doses may be required.

Table 15. Calcium channel blockers (calcium antagonists) in hypertension (adapted from ISH / ASH, 2013)

Name	Doses (mg / day)		Multiplicity of reception
Dihydropyridine:
Amlodipine *
Isradipin	2.5 2 rubles / day	5-10 2 r / day
Lacidipine
Lercanidipine
Nifedipine extended action
Nitrendipine
Felodipine
Non-dihydropyridine (heart rate ** - reducing):
Verapamil
Diltiazem

Notes: * - part of the fixed combination of telmisartan with amlodipine;
** - HR - heart rate.

Table 16. ACE inhibitors in hypertension (adapted from ISH / ASH, 2013)

Table 17. β-blockers in hypertension (adapted from ISH / ASH, 2013)

Name	Doses (mg / day)		Multiplicity of reception
Atenolol *
Betaxolol
Bisoprolol
Carvedilol	3.125 2 r / s	6.25-25 2 r / d
Labetalol
Metoprolol succinate
Metoprolol tartrate		50-100 2 r / s
Nebivolol
Propranolol		40-160 2 r / s

Note: * - currently there is a clear tendency to reduce the use of atenolol in the treatment of hypertension and coronary heart disease.

Place of sartans (angiotensin receptor antagonistsII)

in the treatment of hypertension

In the Expert Recommendations ESC / ESH - 2013, ASH / ISH - 2013 and JNC-8 - 2014 sartans are considered as one of the main, most commonly used classes of antihypertensive drugs. Further down the text, and also in Tables 18-19, the basic data for this class of drugs are presented in the World Recommendations we are discussing.

Table 18 shows the dosage and frequency of use of sartans in hypertension.

Table 18. Sartans in the treatment of hypertension (adapted from ISH / ASH, 2013)

Some pharmacological features of sartans are presented in table 19.

Table 19. Some pharmacological features of sartans (adapted from Kaplan NM, Victor RG, 2010)

A drug *	Half-life, h	Active metabolite	Effect of food intake on absorption	Way excretion	Additional properties
Azisartan				Kidneys - 42%, liver - 55%
Valsartan				Kidneys - 30%, liver - 70%
Irbesartan				Kidneys - 20%, liver - 80%	Weak PPARγ receptor agonist **
Candesartan				Kidneys - 60%, liver - 40%
Losartan				Kidneys - 60%, liver - 40%	Uricosuric
Olmesartan				Kidneys - 10%, liver -90%
Telmisartan				Kidneys - 2%, liver - 98%	PPARγ receptor agonist **
Eprosartan				Kidneys - 30%, liver - 70%	Sympatholytic

Notes: * - for all sartans there are fixed combinations with thiazide / thiazide-like diuretics; ** - the effect on the peroxisome proliferator-activated receptor-γ is stronger in telmisartan, less pronounced in irbesartan - it provides additional beneficial effects on glucose and lipid metabolism.

Sartans, like ACE inhibitors, counteract the renin-angiotensin system. They lower blood pressure by blocking the action of angiotensin II on its AT1 receptor, and thereby block the vasoconstrictor action of these receptors.

Sartans are well tolerated. They do not cause the development of a cough; when using them, angioedema rarely occurs; their effects and benefits are similar to those of ACE inhibitors. Therefore, as a rule, their use is preferable to the use of ACE inhibitors. Like ACE inhibitors, sartans can increase serum creatinine levels by up to 30%, mainly due to decreased pressure in the renal glomeruli and decreased glomerular filtration rate. These changes, usually functional, are reversible (transient) and are not associated with long-term decline in kidney function (considered harmless).

Sartans do not have dose-dependent side effects, which allows the use of medium or even maximum approved doses at the initial stage of treatment (i.e., does not require titration).

Sartans have the same beneficial effects on cardiovascular and renal prognosis as ACE inhibitors.

Like ACE inhibitors, sartans have a more pronounced antihypertensive (and organoprotective) effect on white-skinned and Asian patients; less pronounced in black patients, however, when sartans are used in combination with any calcium channel blocker or diuretic, the effect of treatment becomes independent of race.

There is a unanimous recommendation not to use a combination of sartans with ACE inhibitors; each of these drugs has beneficial reno-protective effects, but in combination, they can have a negative effect on renal prognosis.

At the beginning of the use of sartans in people who are already taking diuretics, it may be helpful to skip the diuretic to prevent a sudden drop in blood pressure.

Sartans should not be used in pregnant women, especially during the 2nd and 3rd trimesters, as they may jeopardize the normal development of the fetus.

Possibilities of Telmisartan

(including fixed combinations

with hydrochlorothiazide and with amlodipine).

Telmisartan is one of the most studied and effective representatives of the sartan class, it is characterized by a powerful and stable antihypertensive effect, the presence of a complex of organoprotective and beneficial metabolic effects, a high level of "evidence base" on a positive effect on the cardiovascular, cerebrovascular and renal prognosis, obtained in the largest randomized controlled trials. A more detailed characterization of telmisartan is presented in table 20.

It is necessary to pay attention to the presence of two variants of fixed combinations of the original telmisartan - a combination with hydrochlorothiazide (40 / 12.5 mg tablets and 80.12.5 mg tablets - Table 20) and a combination with amlodipine (80/5 mg tablets and 80/10 mg - Table 21). Given the priority now given to combination antihypertensive therapy (see below), their use can be considered as one of the important components of the daily management of hypertension.

Table 20. General characteristics of telmisartan and fixed combination of telmisartan with hydrochlorothiazide - 1 part

· Telmisartan (tablets of 80 mg), a fixed combination of telmisartan with hydrochlorothiazide is presented, respectively, 40 and 12.5 mg per tablet, as well as 80 and 12.5 mg per tablet. Telmisartan is a representative of one of the 5 main classes of antihypertensive drugs. It is also used in the treatment of patients with chronic coronary artery disease, diabetes mellitus, chronic kidney disease. · Is one of the most studied representatives of the Sartan class. Has an authoritative "evidence base" on a positive effect on cardiovascular, cerebrovascular and renal prognosis (ONTARGET / TRANSCEND / PROFESS program, etc.). · The positive metabolic effects of telmisartan have been proven (with a decrease in insulin resistance, a decrease in glycemic levels, glycosylated hemoglobin, low density lipoprotein cholesterol, triglycerides). This allows it to be widely used in people with diabetes mellitus, prediabetes, metabolic syndrome, obesity. · There is extensive safety data for telmisartan. It does not cause coughing (unlike ACE inhibitors). To the same extent as ACE inhibitors, it reduces the risk of developing myocardial infarction in persons with an increased cardiovascular risk. Does not increase the risk of developing cancer. The drug is not used in pregnant or lactating women. It should not be combined with ACE inhibitors.

Telmisartan selectively inhibits the binding of angiotensin II (AII) to type 1 receptors for it (AT1) on target cells. This blocks all known effects of AII on these receptors (including vasoconstrictor, aldosterone-secreting, etc.). · When used, levels of plasma aldosterone, C-reactive protein and pro-inflammatory cytokines are reduced. · The half-life is the most significant in comparison with other sartans, it ranges from 20 to 30 hours. The maximum concentration in plasma is achieved within 1 hour after administration, a distinct antihypertensive effect - after 3 hours. It is metabolized in the liver; in this regard, it is highly safe with reduced renal function. · Application - regardless of food intake. The initial dose is 20-40 mg / day for 1 dose, if necessary - up to 80 mg / day. In persons with decreased liver function, the daily dose is no more than 40 mg.

Table 20. General characteristics of telmisartan and fixed combination of telmisartan with hydrochlorothiazide - part 2

· Antihypertensive Effects of Telmisartan well studied. Shown: 1) a high percentage of "responders" when using a dose of 80 mg / day - with the achievement of target values ​​of blood pressure, according to daily monitoring, among persons with hypertension in general - up to 69-81%; 2) smoothness and stability of blood pressure reduction, reaching the maximum of this effect after about 8-10 weeks from the start of use; 3) preservation of antihypertensive action for 24 hours with a single dose during the day; 4) excellent protection against an increase in blood pressure in the early morning hours (which is often the direct cause of the development of cardiovascular complications in persons with hypertension); 5) the absence of tachyphylaxis (decrease in the severity of antihypertensive action) with many months of use; 5) absence of "withdrawal syndrome"; 6) an additional significant increase in the antihypertensive effect when combined with hydrochlorothiazide; 7) placebo-like tolerance. Provided evidence of diverse organo-protective action of telmisartan : 1) regression of left ventricular hypertrophy; 2) a decrease in arterial stiffness and a decrease in endothelial dysfunction; 3) reduction of microalbuminuria and proteinuria in patients with hypertension and type 2 diabetes mellitus. Proven efficacy, excellent tolerance, organoprotection and high patient adherence to treatment motivate the possibility of using telmisartan drugs and a fixed combination of telmisartan with hydrochlorothiazide in the widest contingent of patients with hypertension ... The use of these drugs is justified in persons with hypertension, regardless of gender and age, including both patients with uncomplicated hypertension and those with a combination of hypertension with metabolic syndrome, hyperlipidemia, obesity, diabetes mellitus (type 1 or 2), chronic ischemic heart disease, chronic kidney disease (both diabetic and non-diabetic), as well as post-stroke patients with hypertension.

Table 21. Characteristics of the original fixed combination of telmisartan (80 mg) and amlodipine (5 mg or 10 mg) - 1 part

General characteristics: · Each of the components of this combination is a representative of one of the most commonly used classes of antihypertensive drugs: telmisartan, an angiotensin II receptor antagonist; amlodipine is a calcium channel blocker. The combination of sartan with a calcium channel blocker is justified from a pathophysiological and clinical point of view (for example, mutual strengthening of the antihypertensive effect, reducing the risk of edema in response to amlodipine ). This combination in the current (2013-2014) Recommendations is considered as one of the most preferred ... Such combinations have been successfully used in major studies

Characteristics of fixed combination components telmisartan and amlodipine: Detailed characteristics Telmisartan given in table 20 · Amlodipine - 3rd generation dihydropyridine calcium channel blocker, one of the most prescribed antihypertensive and antianginal drugs in the world. · Does not have adverse effects on the lipid spectrum and glycemia. · Has the longest among the drugs in its class half-life (30-50 hours), which provides him with: 1) a gradual and smooth onset of action; 2) long-term and stable antihypertensive and antianginal effect; 3) the possibility of taking it once a day; 4) high adherence of patients to treatment; 5) there is no risk of an increase in blood pressure and an increase in angina pectoris if the patient accidentally misses a drug intake. The maximum plasma concentration is reached 6-12 hours after ingestion (as a result of which distinct antihypertensive and antianginal effects develop within 6 hours after the first dose). A stable equilibrium of concentration occurs by 7-8 days from the start of administration (the clinical effects of the drug at the beginning of therapy, day by day, can gradually increase and stabilize by 7-8 days). · Reception regardless of the meal. · The drug provides coronary vasodilation, confirmed in major studies (significant antianginal effects - CAPE II, distinct antiatherosclerotic effects (PREVENT, NORMALIZE); improved prognosis in chronic coronary artery disease (PREVENT, CAMELOT). In a number of reputable studies, amlodipine has demonstrated a distinct antihypertensive effect, an improvement in the daily blood pressure profile, a favorable effect on the prognosis in hypertension (including renal and cerebrovascular) and excellent tolerability (ALLHAT, VALUE, ASCOT).

Table 21. Characteristics of the original fixed combination of telmisartan (80 mg) and amlodipine (5 mg or 10 mg) - part 2

Possibilities of using a fixed combination telmisartan and amlodipine for hypertension: · Can be widely used in the treatment of hypertension: 1) regardless of gender and age; 2) as initial therapy or in case of insufficient effectiveness of previous antihypertensive regimens; 3) as the only antihypertensive approach or as part of multicomponent combinations. · It is used in the following categories of patients with hypertension: Ø with uncomplicated essential hypertension (hypertension); Ø with hypertension in the elderly (including those with isolated systolic hypertension, as well as patients with various concomitant conditions); Ø in hypertension in patients with chronic ischemic heart disease (both in the presence of anginal syndrome and in its absence; regardless of myocardial infarction and coronary revascularization procedures; in combination with other standard therapeutic approaches - statins, antithrombotics); Ø with hypertension in persons with diabetes mellitus, metabolic syndrome, hyperlipidemia, obesity; Ø for hypertension in combination with chronic kidney disease - CKD (as well as a renoprotective approach; it is used up to CKD stage 5 inclusive; in persons with CKD stages 3-5, dose reduction is not required); Ø with hypertension in patients with chronic obstructive pulmonary disease; Ø with hypertension in post-stroke patients, in persons with peripheral vascular diseases. · Usual use: 1 tablet once a day, regardless of food intake. Caution is required in persons with reduced liver function. · The drug should not be used if pregnant or breastfeeding.

The choice of treatment tactics:

monotherapy or combination antihypertensive therapy?

Figures 2 and 3 show the approaches to the choice of treatment tactics for hypertension, recommended, respectively, by experts from Europe, 2013 and the USA, 2013.

Figure 2. Approaches to the choice of monotherapy or combination therapy in hypertension ESC-ESH, 2013

Figure 3. Approaches to the choice of treatment tactics in hypertension, USA, 2013

Note: TD - thiazide diuretic; CHF - chronic heart failure; DM - diabetes mellitus; CKD is a chronic kidney disease.

Many patients already at the initial stage of treatment can be prescribed combination antihypertensive therapy two drugs. Figure 4 shows the antihypertensive drug combinations recommended by the ESC-ESH experts in 2013. If necessary, use triple antihypertensive therapy (usually a calcium channel blocker + thiazide diuretic + ACE inhibitor / sartan). It is not recommended to combine an ACE inhibitor with sartan.

If the patient has a high or very high level of additional cardiovascular risk, the treatment strategy should include statin (for example, atorvastatin at a dose of 10 mg / day, in the presence of concomitant coronary artery disease, the dose should be higher) and aspirin (75-100 mg / day, after reaching control of blood pressure, after eating in the evening) - if tolerated and in the absence of contraindications, for continuous use. The main purpose of prescribing statin and aspirin in this case is to reduce the risk of cardiovascular complications.

Figure 4. Combinations of antihypertensive drugs

Note: Combinations indicated green solid line (letter "a" ) are preferred (rational); with a green dashed line (the letter " b ») - also rational, but with some restrictions; black intermittent (letter "c") - possible, but less studied; red line (the letter " d ») not recommended combination is marked.

Conclusion. Summing up the results presented, it can be noted that: 1) when choosing a treatment strategy in patients with hypertension, the general practitioner, family doctor and cardiologist should focus on the target blood pressure levels presented in the new world Recommendations, as well as approaches to the choice of certain classes of antihypertensive drugs ; 2) among the classes of antihypertensive drugs, sartans deserve more attention (than is traditionally the case for most practicing clinicians) - highly effective and safe drugs with favorable versatile organoprotective effects and a positive effect on prognosis; 3) telmisartan (either alone or as fixed combinations with hydrochlorothiazide or amlodipine) may be a good antihypertensive choice an antihypertensive agent in many patients with hypertension .

Conventional abbreviations:

AH - arterial hypertension

BP - blood pressure

ACE - angiotensin converting enzyme

CCB - calcium channel blockers

β-AB - β-blockers

ABPM - 24-hour blood pressure monitoring

GFR - glomerular filtration rate

CKD, a chronic kidney disease

BIBLIOGRAPHY:

1. Sirenko Yu.N. Hypertension and arterial hypertension / Yu. N. Sirenko. - Donetsk: Zaslavsky Publishing House, 2011 .-- 352 p.
2. AHA / ACC Guideline on lifestyle management to reduce cardiovascular risk [Electronic resource] / R.H. Eckel, J.M. Jakicic, J.D. Ard // Circulation. - 2013 .-- 46 p. - Journal access mode: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437740.48606.d1. full.pdf.
3. Campos-Outcalt D. The new cardiovascular disease prevention guidelines: what you need to know / D. Campos-Outcalt // J. Fam. Pract. - 2014. - Vol. 63, no. - P. 89-93.
4. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension [Electronic resource] / M.A. Weber, E.L. Schiffrin, W.B. White // J. Clin. Hypertens. - 2013. - Journal access mode: http://www.ash-us.org/documents/ASH_ISH-Guidelinespdf.
5. ESH / ESC Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) / G. Mancia, R. Fagard, K. Narkiewicz // J. Hypertens. - 2013. - Vol. 31. - P.1281-1357.
6. Evidence-Based guideline for the management of high blood pressure in adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) [Electronic resource] / R.А. James, S. Oparil, B.L. Carter // Amer. Med. Ass. - 2014. - Mode of access to journals: http: //circ.ahajournals.org/content/124/18/2020.full.
7. Ruilope L. M. Long-term adherence to therapy: the clue to prevent hypertension consequences / L. M. Ruilope // Eur. Heart J. - 2013. - Vol.34. - P.2931-2932.

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

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

Definition of arterial hypertension

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

These blood pressure (BP) thresholds are based on the results of randomized controlled trials that have demonstrated the feasibility and benefits of treatment aimed at lowering these blood pressure levels in patients with "essential hypertension" and "symptomatic arterial hypertension".

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

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

Hypertension prevails among all forms of arterial hypertension, its prevalence is over 90%. Due to the fact that HD is a disease that has various variants of its course in the literature, instead of the term "essential hypertension", the term "arterial hypertension (hypertension)" is used.

Etiology and pathogenesis of hypertension

The pathogenesis of hypertension is not fully understood. The hemodynamic basis for an increase in blood pressure is an increase in the tone of arterioles due to hyperactivation of the sympathetic nervous system.

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

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

At least three paths are indicated:

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

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

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

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

Epidemiology of arterial hypertension

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

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

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

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

ICD 10 coding

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

Secondary hypertension

Classification

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

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

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

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

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

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

Table 2 - Threshold blood pressure levels (mm Hg) for the diagnosis of arterial hypertension according to different measurement methods

Category	SBP (mm Hg)		DBP (mmHg)
Office AD	>140	and / or	>90
Outpatient blood pressure
Daytime (wakefulness)	>135	and / or	>85
Night (sleep)	>120	and / or	>70
Daily	>130	and / or	>80
SCUD	>135	and / or	>85

The criteria for elevated blood pressure are largely arbitrary, since there is a direct relationship between blood pressure and the risk of cardiovascular disease (CVD). This relationship starts from relatively low values ​​- 110-115 mm Hg. Art. for SBP and 7075 mm Hg. Art. for DBP.

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

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

Diagnostics

AH diagnosis and examination includes the following steps:

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

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

History of arterial hypertension

Comments: collection of anamnesis includes collection of information about the presence of RF, subclinical symptoms of MOM, a history of CVD, CVD, CKD and secondary forms of hypertension, as well as previous experience in the treatment of hypertension.

Physical examination

Patient with hypertension is aimed at identifying RF, signs of secondary forms of hypertension and organ lesions. Height, body weight are measured with the calculation of the body mass index (BMI) in kg / m2 (determined by dividing the body weight in kilograms by the height in meters squared) and the waist circumference, which is measured in a standing position (the patient should only have underwear, the measuring point is the midpoint of the distance between the apex of the iliac crest and the lower lateral edge of the ribs), the measuring tape should be held horizontally.

• general analysis of blood and urine;
• study of glucose in blood plasma (on an empty stomach);
• study of total cholesterol (TC), high density lipoprotein cholesterol (HDL cholesterol), low density lipoprotein cholesterol (LDL cholesterol), triglycerides (TG);
• study of potassium, sodium in blood serum;

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

The value of blood pressure obtained by the SCAD method correlates more closely with MEM and the prognosis of the disease than clinical blood pressure, and its predictive value is comparable to the method of 24-hour blood pressure monitoring after adjusting for sex and age.

The SCAD method has been proven to increase patient adherence to treatment. A limitation of the use of the SCAD method are those cases when the patient is inclined to use the results obtained for self-correction of therapy.

It should be borne in mind that it cannot provide information on blood pressure levels during the "everyday" (real) daytime activity, especially among the working population, and at night. For SCAD, traditional tonometers with dial gauges can be used, as well as automatic and semi-automatic devices for home use that have passed certification.

To assess the level of blood pressure in situations of a sharp deterioration in the patient's well-being outside of stationary conditions (on trips, at work, etc.), it is possible to recommend the use of automatic wrist blood pressure meters, but with the same rules for measuring blood pressure (2-3 times measurement, the position of the hand at the level of the heart etc.). It should be remembered that BP measured at the wrist may be slightly below the BP level at the shoulder.

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

Only the ABPM method makes it possible to determine the circadian rhythm of blood pressure, nocturnal hypotension or hypertension, the dynamics of blood pressure in the early morning hours, the uniformity and sufficiency of the antihypertensive effect of drugs.

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

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

1. Suspected white coat hypertension.
2. Patients with grade 1 hypertension according to clinical blood pressure.
3. High clinical blood pressure in individuals without POM and in individuals with a low overall cardiovascular risk.
4. Suspicion of "masked" AG.
5. High normal clinical blood pressure.
6. Normal clinical blood pressure in individuals with POM and in individuals with a high overall cardiovascular risk.
7. Revealing "white coat hypertension" in hypertensive patients.
8. Significant fluctuations in clinical blood pressure during the same or different visits to the doctor.
9. Vegetative, orthostatic, postprandial, drug hypotension; hypotension during daytime sleep.
10. Increased clinical blood pressure or suspected preeclampsia in pregnant women.
11. Identification of true and false refractory hypertension.

Specific indications for ABPM:

1. Pronounced discrepancies between the level of clinical blood pressure and SCAD data.
2. Assessment of the circadian rhythm of blood pressure.
3. Suspicion of nocturnal hypertension or no nocturnal decrease in blood pressure, for example, in patients with sleep apnea, CKD, or diabetes.
4. Assessment of blood pressure variability.

CT or MRI methods in patients with hypertension are recommended in order to identify complications of hypertension (asymptomatic cerebral infarctions, lacunar infarctions, microbleeds and white matter lesions in discirculatory encephalopathy, transient ischemic attacks / strokes).

Assessment of the total (total) cardiovascular risk

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

Comments: Identification of target organ damage is recommended because there is evidence that target organ damage is a predictor of cardiovascular mortality independently of SCORE.

Table 3 - Risk stratification in patients with arterial hypertension

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

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

Table 4 - Risk factors affecting prognosis used to stratify total cardiovascular risk

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

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

Diagnosis formulation

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

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

Table 5 - Management tactics of patients depending on the total cardiovascular risk

Risk factors		(mmHg.)
	AG 1st degree 140159 / 90-99	AG 2nd degree 160179 / 100-109	AH 3rd degree> 180/110
No risk factors	Lifestyle changes over several months If hypertension persists, prescribe drug therapy		Change of image life Assign medication therapy
1-2 risk factors	Change in lifestyle within a few weeks If hypertension persists, prescribe drug therapy	Change of image life Assign medication therapy	Change of image life Assign medication therapy
3 or more risk factors	Change of image life Assign medication therapy	Change of image life Assign medication therapy	Change of image life Assign medication therapy

Arterial hypertension treatment

The goals of therapy

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

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

The most important aspect of a patient with hypertension is deciding whether to prescribe antihypertensive therapy. Indications for the appointment of AGT are determined individually based on the value of the total (total) CVR (Table 5).

Lifestyle change activities

Lifestyle interventions are recommended for all hypertensive patients. Non-drug methods of treatment of hypertension contribute to a decrease in blood pressure, reduce the need for antihistamines and increase their effectiveness, allow the correction of RF, to carry out primary prevention of hypertension in patients with high normal blood pressure and those with RF.

Comments: There is strong evidence for a link between salt intake and blood pressure. Excess salt intake may play a role in the development of refractory hypertension. The standard salt intake in many countries is from 9 to 12 g / day (80% of the salt consumed is the so-called "hidden salt"), a decrease in its consumption to 5 g / day in hypertensive patients leads to a decrease in SBP by 4-5 mm Hg ... Art.

The effect of sodium restriction is more pronounced in elderly and senile patients, in patients with diabetes, MS and CKD. Salt restriction can lead to a decrease in the number of antihistamines taken and their doses.

1. Patients are advised to reduce their consumption of alcoholic beverages.
2. Patients are advised to change their diet.
3. Patients are advised to normalize body weight.
4. Increased physical activity is recommended for patients.
5. Smoking cessation is recommended for patients.

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

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

Surgery

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

Hypertension or other arterial hypertension significantly increases the likelihood of stroke, heart attack, vascular disease and chronic kidney disease. Due to morbidity, mortality and costs to society, preventing and treating hypertension is an important public health problem. Fortunately, recent advances and research in this area have led to an improved understanding of the pathophysiology of hypertension and the development of new pharmacological and interventional treatments for this common disease.

Development mechanisms

Why hypertension occurs is still unclear. The mechanism of its development has many factors and is very complex. It involves various chemicals, vascular reactivity and tone, blood viscosity, the work of the heart and nervous system. A genetic predisposition to the development of hypertension is assumed. One of the modern hypotheses is the concept of immune disorders in the body. Immune cells infiltrate target organs (vessels, kidneys) and cause permanent disruption of their work. This has been noted, in particular, in people with HIV infection and in patients who have been taking immunosuppressants for a long time.

In the beginning, labile arterial hypertension is usually formed. It is accompanied by the instability of pressure figures, increased work of the heart, increased vascular tone. This is the first stage of the disease. At this time, diastolic hypertension is often recorded - an increase in only the lower pressure figure. This is especially common in overweight young women and is associated with edema of the vascular wall and increased peripheral resistance.

Subsequently, the increase in pressure becomes permanent, the aorta, heart, kidneys, retina and brain are affected. The second stage of the disease begins. The third stage is characterized by the development of complications from the affected organs - myocardial infarction, renal failure, visual impairment, stroke and other serious conditions. Therefore, even labile arterial hypertension requires timely detection and treatment.

The progression of hypertension usually looks like this:

• transient arterial hypertension (temporary, only with stress or hormonal disruptions) in people 10-30 years old, accompanied by an increase in the output of blood from the heart;
• early, often labile arterial hypertension in persons under 40 years of age, in whom there is already an increase in the resistance to blood flow of small vessels;
• disease with damage to target organs in persons 30-50 years old;
• accession of complications in the elderly; at this time, after a heart attack, the heart muscle weakens, the work of the heart and cardiac output decreases, and blood pressure often decreases - this condition is called "headless hypertension" and is a sign of heart failure.

The development of the disease is closely related to hormonal disorders in the body, primarily in the "renin - angiotensin - aldosterone" system, which is responsible for the amount of water in the body and vascular tone.

Causes of the disease

Essential hypertension, which accounts for up to 95% of all hypertension cases, arises under the influence of external unfavorable factors in combination with a genetic predisposition. However, the specific genetic abnormalities responsible for the development of the disease have not been identified. Of course, there are exceptions when a violation in the work of one gene leads to the development of pathology - this is Liddle's syndrome, some types of adrenal pathology.

Secondary arterial hypertension can be a symptom of various diseases.

Renal causes account for up to 6% of all cases of hypertension and include damage to the tissue (parenchyma) and renal vessels. Renoparenchymal arterial hypertension can occur with the following diseases:

• polycystic;
• chronic kidney disease;
• Liddle's syndrome;
• compression of the urinary tract with a stone or tumor;
• a tumor that secretes renin, a powerful vasoconstrictor.

Renovascular hypertension is associated with damage to the vessels that feed the kidneys:

• coarctation of the aorta;
• vasculitis;
• narrowing of the renal artery;
• collagenosis.

Endocrine arterial hypertension is less common - up to 2% of cases. They can be caused by certain medications, such as anabolic steroids, oral contraceptives, prednisone, or nonsteroidal anti-inflammatory drugs. Alcohol, cocaine, caffeine, nicotine and licorice root preparations also increase blood pressure.

An increase in pressure is accompanied by many diseases of the adrenal glands: pheochromocytoma, increased production of aldosterone, and others.

There is a group of hypertension associated with brain tumors, poliomyelitis, or high intracranial pressure.

Finally, do not forget about these more rare causes of the disease:

• hyperthyroidism and hypothyroidism;
• hypercalcemia;
• hyperparathyroidism;
• acromegaly;
• obstructive sleep apnea syndrome;
• gestational hypertension.

Obstructive sleep apnea is a common cause of high blood pressure. Clinically, it manifests itself as periodic cessation of breathing during sleep due to snoring and the appearance of obstructions in the airways. About half of these patients have high blood pressure. Treatment of this syndrome can normalize hemodynamic parameters and improve the prognosis in patients.

Definition and classification

Types of blood pressure - systolic (develops in the vessels at the time of systole, that is, contraction of the heart) and diastolic (remains in the vascular bed due to its tone during myocardial relaxation).

The grading system is essential for deciding the aggressiveness of a treatment or therapeutic intervention.

Arterial hypertension is an increase in pressure up to 140/90 mm Hg. Art. and higher. Both of these numbers often increase, which is called systolic-diastolic hypertension.

In addition, blood pressure in hypertension may be normal in people on chronic antihypertensive medications. The diagnosis in this case is clear based on the history of the disease.

Prehypertension is spoken of at pressure levels up to 139/89 mm Hg. Art.

Arterial hypertension degree:

• first: up to 159/99 mm Hg. Art .;
• second: from 160 / from 100 mm Hg. Art.

This division is to a certain extent arbitrary, since the pressure indicators differ in the same patient under different conditions.

The classification shown is based on an average of 2 or more values ​​obtained at each of 2 or more visits following an initial check-up with a physician. Unusually low readings should also be evaluated for clinical relevance, because they can not only worsen the patient's well-being, but also be a sign of serious pathology.

Classification of arterial hypertension: it can be primary, developed due to genetic reasons. At the same time, the true cause of the disease remains unknown. Secondary hypertension is caused by various diseases of other organs. Essential (for no apparent reason) arterial hypertension is observed in 95% of all cases in adults and is called essential hypertension. In children, secondary hypertension prevails, which is one of the signs of some other disease.

Severe arterial hypertension, not amenable to treatment, is often associated precisely with an unrecognized secondary form, for example, with primary hyperaldosteronism. An uncontrolled form is diagnosed when three different antihypertensive medications are combined, including a diuretic, and blood pressure does not reach normal.

Clinical signs

Symptoms of arterial hypertension are often only objective, that is, the patient does not feel any complaints until he has damage to target organs. This is the insidiousness of the disease, because at stages II – III, when the heart, kidneys, brain, fundus are already affected, it is almost impossible to reverse these processes.

What signs you need to pay attention to and consult a doctor, or at least start measuring your blood pressure yourself with a tonometer and write it down in your self-control diary:

• dull pain in the left side of the chest;
• heart rhythm disturbances;
• back pain;
• periodic dizziness and tinnitus;
• deterioration of vision, the appearance of spots, "flies" before the eyes;
• shortness of breath on exertion;
• cyanosis of the hands and feet;
• swelling or swelling of the legs;
• attacks of choking or hemoptysis.

An important part of the fight against hypertension is a timely full-fledged clinical examination, which each person can undergo for free in his clinic. There are also Health Centers throughout the country, where doctors will tell you about the disease and conduct its initial diagnosis.

Hypertensive crisis and its danger

With a hypertensive crisis, the pressure increases to 190/110 mm Hg. Art. and more. Such arterial hypertension can cause damage to internal organs and various complications:

• neurological: hypertensive encephalopathy, cerebral vascular accidents, cerebral infarction, subarachnoid hemorrhage, intracranial hemorrhage;
• cardiovascular: myocardial ischemia / infarction, acute pulmonary edema, aortic dissection, unstable angina pectoris;
• others: acute renal failure, retinopathy with loss of vision, eclampsia in pregnant women, microangiopathic hemolytic anemia.

A hypertensive crisis requires immediate medical attention.

Gestational hypertension is part of the so-called OPG-gestosis. If you do not seek help from a doctor, you may develop preeclampsia and eclampsia - conditions that threaten the life of the mother and fetus.

Diagnosis

Diagnostics of arterial hypertension necessarily includes accurate measurement of the patient's pressure, targeted collection of anamnesis, general examination and obtaining laboratory and instrumental data, including a 12-channel electrocardiogram. These steps are required to determine the following provisions:

• damage to target organs (heart, brain, kidneys, eyes);
• probable causes of hypertension;
• baseline values ​​for further evaluation of the biochemical effects of therapy.

On the basis of a certain clinical picture or if secondary hypertension is suspected, other studies can be performed - the level of uric acid in the blood, microalbuminuria (protein in the urine).

• echocardiography to determine the condition of the heart;
• ultrasound examination of internal organs to exclude damage to the kidneys and adrenal glands;
• tetrapolar rheography to determine the type of hemodynamics (treatment may depend on this);
• monitoring of pressure on an outpatient basis to clarify fluctuations during the day and night;
• daily monitoring of the electrocardiogram, combined with the determination of sleep apnea.

If necessary, an examination by a neurologist, ophthalmologist, endocrinologist, nephrologist and other specialists is prescribed, differential diagnosis of secondary (symptomatic) hypertension is carried out.

Treatment of arterial hypertension involves lifestyle adjustments as a first step.

Lifestyle

Reducing blood pressure and heart risk is possible if at least 2 of the following rules are followed:

• weight reduction (with a loss of 10 kg, the pressure decreases by 5 - 20 mm Hg);
• reducing alcohol consumption to 30 mg ethanol for men and 15 mg ethanol for women of normal weight per day;
• salt intake no more than 6 grams per day;
• sufficient intake of potassium, calcium and magnesium from food;
• to give up smoking;
• Reducing the intake of saturated fat (that is, solid, animal) and cholesterol;
• aerobic exercise for half an hour a day almost daily.

Drug treatment

If, despite all measures, arterial hypertension persists, there are various options for drug therapy. In the absence of contraindications and only after consultation with a doctor, the first-line drug is usually a diuretic. It must be remembered that self-medication can cause irreversible negative consequences in patients with hypertension.

If there is a risk or an additional condition that has already developed, other components are included in the treatment regimen: ACE inhibitors (enalapril and others), calcium antagonists, beta-blockers, angiotensin receptor blockers, aldosterone antagonists in various combinations. The selection of therapy is carried out on an outpatient basis for a long time until the optimal combination for the patient is found. It will need to be used constantly.

Patient information

Hypertension is a lifelong illness. It is impossible to get rid of it, with the exception of secondary hypertension. For optimal control over the disease, constant self-improvement and medical treatment are required. The patient should attend the High Blood Pressure School because adherence to treatment reduces cardiovascular risk and increases life expectancy.

What a patient with hypertension should know and do:

• maintain normal weight and waist circumference;
• constantly exercise;
• eat less salt, fat and cholesterol;
• consume more minerals, in particular potassium, magnesium, calcium;
• limit the use of alcoholic beverages;
• quit smoking and the use of psychostimulating substances.

Regular blood pressure monitoring, doctor visits and behavior correction will help a hypertensive patient maintain a high quality of life for many years.

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Features of hypertension 3 degrees

1. What is 3 degree of hypertension
2. Risk groups of patients with essential hypertension
3. Symptoms
4. What to look for
5. Reasons for the development of grade 3 hypertension

Hypertension is a fairly common problem. The most dangerous option is the 3rd degree of this disease, however, when making a diagnosis, indicate the stage and degree of risk.

People who have high blood pressure should understand what this threatens in order to take adequate measures in time and not increase the already high risk of complications. For example, if a diagnosis of hypertension is risk 3, what is it, what do these numbers mean?

They mean that in a person with such a diagnosis, the risk of getting a complication due to hypertension is from 20 to 30%. If this indicator is exceeded, a diagnosis of grade 3 hypertension, risk 4. Both diagnoses mean the need for urgent treatment.

What is 3 degree of hypertension

This degree of the disease is considered severe. It is determined by blood pressure indicators, which look like this:

• Systolic pressure 180 or more mm Hg;
• Diastolic - 110 mm Hg and higher.

At the same time, the blood pressure level is always elevated and is almost constantly held at the levels that are considered critical.

Risk groups of patients with essential hypertension

In total, it is customary to distinguish 4 such groups, depending on the likelihood of damage to the heart, blood vessels and other target organs, as well as on the presence of burdening factors:

• 1 risk - less than 15%, no aggravating factors;
• 2 risk - from 15 to 20%, no more than three aggravating factors;
• 3 risk - 20-30%, more than three aggravating factors;
• 4 risk - above 30%, aggravating factors more than three, there is damage to target organs.

Aggravating factors include smoking, insufficient physical activity, excess weight, a state of chronic stress, poor nutrition, diabetes mellitus, endocrine disorders.

With grade 3 hypertension with risk 3, there is a threat to health. A lot of patients are in the 4th risk group. A high risk is possible even with lower blood pressure values, since each organism is individual and has its own margin of safety.

In addition to the degree and risk group, the stage of hypertension is also determined:

• 1 - there are no changes or injuries in the target organs;
• 2 - changes in several target organs;
• 3 - in addition to damage to target organs, plus complications: heart attack, stroke.

Symptoms

With the development of hypertension up to grade 3 with risks 3 and 4, it is impossible not to notice the symptoms, because they appear quite brightly. The main symptom is a critical level of blood pressure, which causes all other manifestations of the disease.

Possible manifestations:

• Dizziness and throbbing headaches;
• Flashing "flies" before the eyes;
• General worsening of the condition;
• Weakness in the arms and legs;
• Vision problems.

Why do these symptoms occur? The main problem with hypertension is damage to vascular tissue. High blood pressure increases the load on the vascular wall.

In response to this, the inner layer is damaged, and the muscle layer of the vessels increases, due to which their lumen narrows. For the same reason, the vessels become not so elastic, cholesterol plaques form on their walls, the lumen of the vessels narrows even more, and blood circulation is even more difficult.

In general, the health risk is very high, and grade 3 hypertension with risk 3 threatens disability quite realistically. Target organs are especially affected:

• Heart;
• Kidneys;
• Brain;
• Retina.

What's going on in the heart

The left ventricle of the heart expands, the muscle layer in its walls grows, and the elastic properties of the myocardium deteriorate. Over time, the left ventricle is not able to fully cope with its functions, which threatens the development of heart failure, if timely adequate measures are not taken.

Kidney damage

The kidneys are an organ that is abundantly supplied with blood, so they often suffer from high blood pressure. Damage to the renal vessels impairs their blood supply.

The result is chronic renal failure, since destructive processes in the vessels lead to changes in the tissues, for this reason the functions of the organ are disrupted. Kidney damage is possible with hypertension stage 2, grade 3 risk 3.

In case of hypertension, the brain also suffers from blood supply disturbances. This is due to sclerosis and a decrease in the tone of the vessels, the brain itself, as well as the arteries along the spine.

The situation is aggravated if the patient's vessels are highly tortuous, which often happens in this part of the body, since tortuosity promotes the formation of blood clots. As a result, in hypertensive disease, without timely adequate assistance, the brain does not receive enough nutrition and oxygen.

The patient's memory deteriorates, attention decreases. The development of encephalopathy, accompanied by a decrease in intelligence, is possible. These are very unpleasant consequences, as they can lead to loss of performance.

The formation of blood clots in the vessels supplying the brain increases the likelihood of ischemic stroke, and the separation of a blood clot can lead to hemorrhagic stroke. The consequences of such conditions can be catastrophic for the body.

Effects on the organs of vision

In some patients with grade 3 hypertensive disease with grade 3 risk, retinal vascular damage occurs. This negatively affects visual acuity, it decreases, and flashing "flies" in front of the eyes is also possible. Sometimes a person feels pressure on the eyeballs, in this state he constantly feels drowsiness, performance decreases.

Another danger is hemorrhage

One of the formidable complications of grade 3 hypertension with a risk of 3 is hemorrhage in various organs. This happens for two reasons.

1. First, the thickening walls of blood vessels lose their elasticity so much that they become brittle.
2. Secondly, hemorrhages are possible at the site of the aneurysm, because here the walls of the vessels become thinner from overflow and easily break.

Minor bleeding as a result of a ruptured vessel or aneurysm leads to the formation of hematomas; in the case of large ruptures, hematomas can be large-scale and damage internal organs. Severe bleeding is also possible and requires urgent medical attention to stop.

There is an opinion that a person immediately feels high blood pressure, but this does not always happen. Each has its own individual threshold of sensitivity.

The most common variant of the development of hypertension is the absence of symptoms until the onset of a hypertensive crisis. This already means the presence of hypertension of the 2nd degree of the 3rd stage, since this condition indicates organ damage.

The period of the asymptomatic course of the disease can be quite long. If a hypertensive crisis does not occur, then the first symptoms gradually appear, which the patient often does not pay attention to, attributing everything to fatigue or stress. This period may even last until the development of grade 2 arterial hypertension with a risk of 3.

What to look for

• Regular dizziness and headaches;
• A feeling of tightness in the temples and heaviness in the head;
• Noise in ears;
• "Flies" before the eyes;
• General decrease in tone4
• Sleep disturbances.

If you do not pay attention to these symptoms, then the process goes on, and the increased load on the vessels gradually damages them, they cope with work worse and worse, the risks grow. The disease progresses to the next stage and the next degree. Arterial hypertension grade 3 risk 3 can progress very quickly.

As a result, more serious symptoms appear:

• Irritability;
• Decreased memory;
• Shortness of breath with little exercise;
• Visual impairment;
• Interruptions in the work of the heart.

In case of grade 3 hypertension, risk 3 the likelihood of disability is high due to large-scale vascular damage.

Reasons for the development of grade 3 hypertension

The main reason for the development of such a serious condition as grade 3 hypertension is the lack of treatment or insufficient therapy. This can happen, both through the fault of the doctor and the patient himself.

If the doctor is inexperienced or inattentive and has developed an inappropriate treatment regimen, then it will not be possible to lower blood pressure and stop the destructive processes. The same problem lies in wait for patients who are inattentive to themselves and do not follow the prescriptions of a specialist.

For a correct diagnosis, anamnesis is very important, that is, information obtained during examination, acquaintance with documents and from the patient himself. Complaints, blood pressure indicators, complications are taken into account. Blood pressure should be measured regularly.

To make a diagnosis, the doctor needs follow-up data. To do this, you need to measure this indicator twice a day for two weeks. Blood pressure measurement data allow you to assess the state of the vessels.

Other diagnostic measures

• Listening to lungs and heart sounds;
• Percussion of the vascular bundle;
• Determination of the configuration of the heart;
• Electrocardiogram;
• Ultrasound of the heart, kidneys and other organs.

To clarify the state of the body, it is necessary to do tests:

• Plasma glucose;
• General analysis of blood and urine;
• The level of creatinine, uric acid, potassium;
• Determination of creatinine clearance.

In addition, the doctor can prescribe additional examinations required by a particular patient. In patients with stage 3 hypertension, grade 3, risk 3, there are additional aggravating factors that require even more careful attention.

Treatment of hypertension 3 stage risk 3 implies a complex of measures, which includes drug therapy, diet and an active lifestyle. It is imperative to quit bad habits - smoking and drinking alcohol. These factors significantly aggravate the condition of the blood vessels and increase the risks.

For the treatment of hypertension with risks 3 and 4, drug treatment with one drug will not be sufficient. A combination of drugs from different groups is required.

To ensure the stability of blood pressure indicators, mainly prolonged-release drugs are prescribed, which last up to 24 hours. The selection of drugs for the treatment of grade 3 hypertension is carried out based not only on blood pressure indicators, but also on the presence of complications and other diseases. Prescribed drugs should not have side effects undesirable for a particular patient.

The main groups of drugs

• Diuretic;
• ACE inhibitors;
• β-blockers;
• Calcium channel blockers;
• AT2 receptor blockers.

In addition to drug therapy, you must adhere to the diet, work and rest, give yourself a feasible load. The results of the treatment may not be felt immediately after the start. It takes a long time for symptoms to begin to improve.

Appropriate nutrition for hypertension is an important part of treatment.

We will have to exclude foods that contribute to the rise in pressure and the accumulation of cholesterol in the vessels.

Salt consumption should be minimized, ideally no more than half a teaspoon per day.

Prohibited foods

• Smoked products;
• Pickles;
• Spicy dishes;
• Coffee;
• Semi-finished products;
• Strong tea.

It is impossible to completely cure arterial hypertension 3 degree risk 3, however, it is really impossible to stop the destructive processes and help the body to recover. The life expectancy of patients with grade 3 hypertension depends on the degree of development of the disease, the timeliness and quality of treatment, and the patient's compliance with the recommendations of the attending physician.