Modern principles of antihypertensive therapy and prevention. Safe antihypertensive therapy: blood pressure lowering or control

Since the beginning of the 20th century, the combination arterial hypertension(AH) with obesity and diabetes mellitus(SD) has been the subject of active attention from theoretical and practical medicine. A long-term search for the causes that unite these diseases allowed G. Reaven in 1988 to suggest that insulin resistance (IR) and hyperinsulinemia (HI) play an important role in the development of such a pathophysiological condition that combines hypertension, impaired carbohydrate and lipid metabolism and obesity. ) . Subsequently, many studies have confirmed the connection known factors risk cardiovascular diseases and IR. Currently, “metabolic syndrome” (MS) is still the object of close attention of doctors of various specialties. The criteria for diagnosing MS are constantly undergoing changes, periodically supplemented with new characteristics, but invariably since the time of G. Reaven, it includes increased blood pressure (BP), violation carbohydrate metabolism, dyslipidemia and obesity.

In 2007 All-Russian scientific society cardiologists have developed the following criteria for MS: abdominal obesity(waist circumference more than 80 cm in women and 94 cm in men), hypertension, increased triglyceride levels (≥ 1.7 mmol/l), decreased lipoprotein cholesterol levels high density(HDL-C) (< 1,0 ммоль/л у мужчин; < 1,2 ммоль/л у женщин), повышение уровня ХС липопротеидов низкой плотности (ЛПНП) (>3.0 mmol/l), fasting hyperglycemia (fasting plasma glucose ≥ 6.1 mmol/l), impaired glucose tolerance (IGT) (plasma glucose 2 hours after a glucose load between ≥ 7.8 and ≤ 11.1 mmol/l).

Pathogenesis of hypertension in MS. Impaired glucose utilization and an increase in its content in the blood as a result of insulin resistance have a stimulating effect on the beta cells of the islets of Langerhans in the pancreas and are the main cause of the development of adaptive hyperthyroidism. The pathogenetic role of GI in the occurrence of hypertension in MS is currently beyond doubt and is well documented. Available convincing evidence direct involvement of chronic excess insulin in the manifestation of hypertension, both in the form of a direct effect on the tone of vascular smooth muscles and the activity of beta-adrenergic receptors vascular wall, and in enhancing the reabsorption of water and sodium in the kidneys, increasing the activity of the sympathoadrenal and renin-angiotensin systems. Along with this, the stimulating effect of insulin on the processes of proliferation of smooth muscle cells and fibroblasts of the vascular wall has been proven. However, not only changes in metabolism and architectonics of the vascular wall determine the effect of GI on the development of hypertension, but also the effect on the vascular endothelium and platelets in the form of increased production of endothelin, thromboxane A2, prostaglandin F2 and a decrease in the secretion of prostacyclin and nitric oxide.

Therapy of hypertension in MS. According to the third revision of Russian recommendations on hypertension, the main goal of treatment for patients with hypertension remains the maximum reduction in the risk of developing cardiovascular complications (CVD) and death from them. Since patients with MS belong to the category of people with high level risk, the effectiveness of antihypertensive therapy should be determined not only by the ability of the drug to reduce blood pressure, but also by the ability to have a maximum effect on the total cardiovascular risk. In addition, when selecting antihypertensive therapy, the possible negative metabolic effects of a number of drugs should be taken into account. As the well-known TROPHY study showed, the effectiveness of low doses of thiazide diuretics in obese patients is insufficient in most cases. To achieve an adequate antihypertensive effect, a significant increase in the dose of the drug is required. However, for patients with carbohydrate metabolism disorders, the appointment high doses drugs are undesirable due to worsening insulin resistance and negative effects on other types of metabolism. Diuretics tend to cause hyperglycemia, hyperlipidemia, hyperuricemia, hypokalemia, hypercalcemia.

Beta-adrenergic blockers also tend to worsen lipid profile and worsening insulin resistance, so they can hardly be considered drugs of choice in patients with MS. Such pro-atherogenic and pro-diabetogenic effects of antihypertensive therapy are undesirable, since in the long term they can increase the risk of developing diabetes and reduce the effectiveness of therapy in terms of preventing cardiovascular complications. In addition, as studies show, by the ability to cause regression of left ventricular myocardial hypertrophy and slow down the decline in speed glomerular filtration beta blockers are significantly inferior to angiotensin-converting enzyme inhibitors (ACEIs), calcium antagonists (CAs) and angiotensin II receptor antagonists (ATII), which are generally metabolically neutral and do not cause negative influence on tissue sensitivity to insulin.

ACE inhibitors are a very promising group in the treatment of patients with hypertension and MS, since the pathogenetic rationale for their use is associated with activation of the renin-angiotensin-aldosterone system (RAAS) in IR. In addition, their mechanism of action predisposes to many positive effects, proven in large-scale randomized studies. Thus, a decrease in IR and an improvement in glycemic control are known; no negative effect on lipid and purine metabolism s (studies CAPPP, FASET, ABCD, HOPE, UKPDS). Vasoprotective, anti-atherosclerotic (SECURE-HOPE-substudy), as well as nephroprotective effects of ACE inhibitors in diabetic and non-diabetic nephropathy (FACET, MICRO-HOPE, REIN, EUCLID, AIPRI, BRILLIANT) were obtained. Correction of endothelial dysfunction, beneficial effects on platelet hemostasis and fibrinolysis (TREND) are substantiated.

No less promising drugs for the treatment of patients with hypertension and MS are long-acting AA, the main advantage of which is metabolic neutral action on carbohydrate, lipid, purine metabolism with high antihypertensive activity. The antihypertensive effect of AA is based on the ability to cause peripheral vasodilation through inactivation of voltage-dependent calcium channels in the vascular wall.

The undoubted effectiveness of using AK various groups very convincingly demonstrated in numerous international multicenter studies. Along with high antihypertensive activity, it has been proven beneficial influence on the frequency of fatal and non-fatal strokes, myocardial infarction, sudden death, death from cardiovascular causes (SHE, SHC, NORDIL, VHAT, ALLHAT, HOT, NICS-EH, ASCT, STOP-Hypertension 2, VALUE, SYST-EUR). A decrease in IR, a decrease in basal and glucose-stimulated insulin levels, and a normalization of the insulin response to the glycemic load were found. A slowdown in the progression of the atherosclerotic process has been shown, regardless of the hypotensive effect (INSIGHT, ELSA, CAMELOT). The antispastic effect of AK and the effect on myocardial ischemia (CAPE) have also been registered. Nephroprotective and vasoprotective effects were noted (PREVENT, INSIGHT, ELSA MIDAS). In addition, regression of left ventricular hypertrophy (TOMH) is substantiated. The use of AKs currently seems extremely promising III generation- amlodipine, whose cardio- and nephroprotective effects are comparable to ACE inhibitors.

Thus, modern requirements for antihypertensive therapy priority which, undoubtedly, is an adequate reduction in blood pressure, are based, at a minimum, on its metabolic neutrality, as well as on the ability to provide additional beneficial effects in relation to the cluster of concomitant metabolic changes.

Since patients with MS are included in the group high risk, then the main strategy for the treatment of hypertension is combination therapy with drugs different groups. Important advantages combination therapy are: the possibility of potentiating the antihypertensive effect both due to the multidirectional action of drugs on the totality of individual pressor mechanisms for the development of hypertension in a particular patient, and due to the mutual suppression of counter-regulatory mechanisms that reduce their effectiveness; reduction in incidence side effects due to lower doses of combined drugs; ensuring the most effective organ protection and reducing the risk and number of cardiovascular events.

IN Lately there is genuine interest in using clinical practice combinations of ACE inhibitors with dihydropyridine AKs. Fundamental in this aspect was the ASCOT-BPLA study, which ended in 2004, which convincingly demonstrated a significant and significantly greater effect of the combination of “dihydropyridine AK (amlodipine 5-10 mg/day) plus ACE inhibitor (perindopril 4-8 mg/day)” compared with combination of “beta blocker (atenolol 50-100 mg/day) plus diuretic (bendroflumethiazide 1.25-2.5 mg/day)” not only on blood pressure levels, but also on the development of cardiovascular complications. Thus, there was a decrease of 11% in deaths from all causes, by 13% in non-fatal myocardial infarction and in all deaths from coronary disease heart disease (CHD), 24% of all deaths due to cardiovascular causes, by 23% - fatal and non-fatal strokes, by 13% - non-fatal myocardial infarction, fatal ischemic heart disease, fatal and non-fatal heart failure, stable and unstable angina(“common coronary point”), by 16% - of all cardiovascular events and revascularization procedures. Moreover, the likelihood of developing new cases of diabetes in the group of patients receiving amlodipine and perindopril was 30% lower, which proved the safety of the combination of dihydropyridine AK plus ACE inhibitors.

The complementary effect of ACE inhibitors and AKIs is the possible effective influence on the pathogenesis of hypertension in MS. The renin-angiotensin system (RAS) and the sympathetic nervous system (SNS) are interactive systems that provide fine regulation of the activity of the heart and blood vessels. different levels: central, baroreceptor, adrenal, postsynaptic ATI receptors. ATII, by binding to presynaptic receptors of noradrenergic neurons of the SNS, increases the level of presynaptic release of norepinephrine, thereby causing vasoconstriction and an increase in peripheral vascular resistance. Along with this, acting postsynaptically, it enhances the contractile response to stimulation of vascular alpha-adrenergic receptors. Next, a vicious circle is formed: ATII activates efferent sympathetic activity, which leads to stimulation of beta-adrenergic receptors of the juxtaglomerular apparatus of the kidneys and promotes the formation of renin by the kidneys. As a result, there is an increase in the amount of ATII, which facilitates the release of norepinephrine at the adrenergic synapses of the adrenal glands. It is the increase in sympathetic tone that is pathophysiologically associated with the formation of GI, which is one of the key mechanisms of changes that develop in MS.

At a certain stage of quite successful antihypertensive therapy, a decrease in blood pressure often contributes to reflex activation of the SNS and RAS. As a result, the effectiveness of antihypertensive therapy is reduced. In addition, the most important hemodynamic consequence of autonomic imbalance may be an increase in myocardial oxygen demand, which is an important predisposing factor in the formation of complications, which is especially important in patients with left ventricular hypertrophy, coronary atherosclerosis, endothelial dysfunction.

Dihydropyridine AKs (especially the short-acting form of nifedipine), reducing blood pressure, cause quite pronounced vasodilation, which causes reflex activation of the SNS. The presence of an intrinsic natriuretic effect in dihydropyridine AAs may contribute to a compensatory increase in RAS activity. Adding ACE inhibitors to therapy makes it possible to overcome the activation of the SAS and RAS, thus enhancing hypotensive effect AK. In the low-renin form of hypertension, when the activity of ACE inhibitors is insufficient, the addition of dihydropyridine AK to therapy provides a slight increase in the activity of the RAS and, thus, enhances the effect of ACE inhibitors.

Control cardiovascular risk suggests, in addition to lowering blood pressure, an effect on possible mechanisms target organ damage at the stages of the cardiovascular and renal continuum. In this regard, the combination of “dihydropyridine AK plus ACEI” is quite justified, since there is convincing evidence of the significant nephroprotective effect of the combination of AK and ACEI. Thus, the effectiveness of the combination of verapamil with the ACE inhibitor trandolapril in patients with diabetic nephropathy(EDICTA, TRAVEND, BENEDICT). There is evidence of a decrease in the severity of microalbuminuria in patients with diabetes when using nitrendipine (SYST-EUR), a slower decline in renal function when using nifedipine in the form of a gastrointestinal therapeutic system (INSIGHT). Also interesting are the results of a double-blind randomized clinical trial (RCT), in which patients with type 1 diabetes and nephropathy who were on constant therapy maximum doses lisinopril, there was a significant decrease in the albumin/creatinine ratio in urine by 54% when amlodipine (10 mg/day) was added to the main treatment and by 56% when candesartan (16 mg/day) was added to the treatment. At the same time, the decrease in albuminuria in both groups did not correlate with the degree of decrease in blood pressure, which proves the actual nephroprotective effect of the drugs.

The possibility of a significant anti-atherosclerotic effect when using a combination of dihydropyridine AK and ACE inhibitors is also promising. Today, the antiatherogenic properties of AKs are their most significant clinical advantage and have been registered in absolutely all representatives of this class. Therefore, the fixed combination of “dihydropyridine AK plus ACEI” is quite capable of providing organ protection in patients with hypertension and MS.

The combination of a dihydropyridine AK and an ACE inhibitor also makes it possible to prevent the occurrence of some adverse effects inherent in their components. Thus, the undoubted advantage of this combination is the ability of ACE inhibitors to prevent swelling of the legs, which develops while taking AA and is a consequence of arteriolar vasodilation, leading to intracapillary hypertension and increased exudation of fluid from the capillaries into the interstitial space. Since there is no increase in circulating plasma volume and sodium retention during the use of AKs due to their own natriuretic effect, edema does not decrease with the use of diuretics, but develops less frequently when prescribing drugs with venodilating properties, in particular, ACE inhibitors.

Dose-dependent effects of AA, such as reflex tachycardia, headaches, hot flashes and facial flushing, also resulting from arteriolar vasodilation, occur less frequently with joint use AK and ACE inhibitors, since fixed combinations allow the use of AK in lower doses without loss of overall antihypertensive effectiveness.

Thus, as F. Messerli predicted back in 1992, obtaining a highly effective fixed combination of metabolically neutral dihydropyridine AK and ACE inhibitors can truly become the “Rolls Royce” of modern antihypertensive therapy in patients with MS.

Among the currently existing combinations of dihydropyridine AK and ACE inhibitors, the fixed combination of amlodipine (Normodipine) 5 mg and lisinopril (Diroton) 10 mg, recently registered in Russia under the name Equator®, is of particular interest.

The most interesting data on the use of the combination of amlodipine and lisinopril in the drug Equator® were obtained during the multicenter, double-blind, placebo-controlled study HAMLET, which studied the effectiveness and safety of the new fixed-dose combination. The study included 195 patients (109 men and 86 women) with untreated or poorly controlled hypertension of I-II degree (BP 140-179/90-99 mm Hg) aged 18-65 years ( average age 48.6 ± 10 years), body mass index 27.7 ± 3.7 kg/m2. Exclusion criteria: symptomatic hypertension; a history of heart attack or stroke within the three months preceding the study. In addition, patients were not included in the study if they had chronic renal failure, malignant neoplasms, severe liver or lung disease, hyperkalemia, obesity (body mass index > 35 kg/m2).

During a run-in period of 14 days, patients took placebo. Subsequently, patients were assigned to a group receiving lisinopril 10 mg/day, or a group receiving amlodipine (5 mg/day), or a group receiving lisinopril in combination with amlodipine in the same doses. The duration of observation was 8 weeks. Blood pressure levels were measured on the day of inclusion (day -14), at the beginning of the study (day 0), and at the end of the 2nd and 8th weeks of drug administration. The criteria for a positive response to treatment was a decrease in blood pressure by at least 20/10 mmHg. Art.

Stopped taking medications early due to adverse events 3 patients (one due to headache, the second due to increased blood pressure during the placebo period, the third due to the need for intracardiac examination and upcoming heart surgery). In the lisinopril group, treatment-related complaints were identified in 8 patients, and unrelated to treatment complaints in 5 cases. In the amlodipine group, treatment-related adverse effects were noted by 9 patients, and treatment-related adverse effects were noted by 7 patients. In the combination therapy group, 7 patients experienced events that were probably related to therapy, and 7 patients that were not related to the drug. Although the complaints present in all groups did not prevent the continuation of treatment.

By the end of observation in the amlodipine group, blood pressure decreased from 155.4 ± 10.2/97.7 ± 4.9 to 140.8 ± 13.7/86.3 ± 7.1 mm Hg. Art.; in the lisinopril group - from 156.4 ± 10.4/97.3 ± 5.7 to 139.8 ± 12.9/87.2 ± 7.7 mm Hg. Art.; in the combination therapy group - from 156.4 ± 9.6/97.5 ± 5.0 to 136.3 ± 11.9/86.0 ± 6.6 mm Hg. Art.

Moreover, in the combination therapy group, systolic blood pressure (SBP) decreased significantly more than in the amlodipine group (-20.1 ± 13.6 and -14.7 ± 13.0 mm Hg, respectively). The reduction in SBP in the combination therapy group also exceeded the changes in pressure in the lisinopril group (-16.8 ± 10.2), but the differences were not statistically significant. There were statistically significant differences between the combination therapy group and the general group receiving any type of monotherapy (p< 0,0236). Maximum effect drugs in relation to diastolic blood pressure (DBP) did not show statistically significant differences between the three groups.

At the end of the study, the proportion of individuals who achieved the target blood pressure level, according to established criteria, was significantly greater in the combination therapy group compared with the amlodipine group (90.1% versus 79.3%; p = 0.0333) or lisinopril (75.8 %; p = 0.0080), as well as in comparison with the generalized data of patients receiving any type of monotherapy (p = 0.0098). There were no statistically significant differences between the two groups of patients receiving monotherapy.

The HAMLET trial is the only RCT to evaluate the antihypertensive efficacy of a fixed combination of two well-studied drugs, lisinopril and amlodipine (Equator®). Of course, the additive organoprotective effect of the drug cannot be based on a simple summation of the effects obtained in independent studies involving amlodipine and lisinopril. Obviously, there is still work to be done in this area. additional research. However, today the high antihypertensive effect and good tolerability profile make it possible to recommend the drug Equator® for use in clinical practice in patients with hypertension and MS. What awaits us along the way? Having experience, we hope that the use of a fixed combination will ensure multiple potentiation of the organoprotective properties of its components and will minimize the frequency adverse reactions, which is very important for increasing the adherence of patients with hypertension to treatment and reducing the risk of cardiovascular complications.

For questions regarding literature, please contact the editor.

M. I. Shchupina, candidate medical sciences, assistant professor
Omsk State Medical Academy, Omsk

Antihypertensive therapy is a way of treating arterial hypertension using several groups of drugs that are used daily. The patient’s well-being depends on how strictly he follows all the doctor’s recommendations.

Arterial hypertension increases the risk of developing heart disease several times and vascular system, including myocardial infarction, atherosclerosis, ischemia and many other complications. This disease is chronic nature, characterized by increased blood pressure.

Symptoms high blood pressure:

• cardiopalmus;
• dyspnea;
• headache;
• state of anxiety, emotional excitement;
• increased sweating;
• nausea;
• swelling of the face and limbs, especially after sleep;
• weakness, decreased performance, fatigue.

The technique of antihypertensive therapy is simple; it consists of observing the following rules:

1. Medicines to correct blood pressure are taken constantly throughout life. Regardless of the level of pressure, medications are taken daily. Only when regular use medications, it becomes possible to avoid the development of work complications or damage to the heart and blood vessels.
2. Antihypertensive drugs are used in dosage form and the dosage recommended by the attending physician. Unauthorized replacement of a drug with analogues or changing the prescribed dose negatively affects the course of treatment and its result.
3. Given the continuous use of drugs, blood pressure must be measured regularly - at least twice a week. This procedure is carried out to monitor the effectiveness of treatment and to allow a quick response when deviations occur.
4. If at proper treatment cases arise sharp increase Blood pressure, it is not recommended to increase the dose of the drug on your own. For regular long-term use Long-acting drugs are prescribed, the effect of which occurs after some time, gradually. For an urgent response to pressure surges, drugs with a short duration of action are used, the hypotensive result of which occurs in a short time.

Treatment is usually started with one drug in a small dosage. Then, under the supervision of a doctor, blood pressure indicators are monitored, after which it is possible to increase the dose or use a combination of two, and in some cases, three drugs.

Drugs used

All drugs prescribed for antihypertensive therapy are divided into the following classes:

• beta blockers;
• ACE inhibitors;
• calcium antagonists;
• diuretics;
• angiotensin II receptor blockers.

Each group has its own characteristics, based on which their application for different categories patients. When treating the underlying disease (arterial hypertension), it is necessary to simultaneously treat concomitant diseases, the development of which was provoked by hypertension.

These include: pathological changes cerebral circulation, diabetes mellitus, retinal retinopathy, kidney damage, atherosclerosis, coronary heart disease and other complications.

Beta blockers

Prescribed to patients with heart problems, approved for the treatment of people who have previously had a heart attack. Medicines in this group reduce the likelihood of complications in patients with:

• angina pectoris;
• elevated heart rate;
• vascular diseases.

The use of these drugs is undesirable for patients with metabolic disorders (including lipids) and diabetes mellitus.

Most known drugs this group: “Betacard”, “Bisoprolol”, “Metocor”, “Acridilol”, “Binelol”, “Esmolol”, “Betaxolol”.

ACE inhibitors

This group medicines recommended for people suffering from metabolic disorders in the body, high blood glucose levels, renal failure. By their action, these drugs not only control blood pressure levels, but also prevent the development of work disorders circulatory system, reduce the risk of vascular damage and kidney pathologies. The medications are tolerated without any complications, do not affect metabolism, and do not increase sugar levels.

Among them, the most popular are: “Enalapril”, “Lisinoton”, “Parnavel”, “Blokordil”, “Spirapril”, “Lotensin”, “Ramipril”.

Calcium antagonists

They are used to prevent coronary disease in patients who have previously had such problems. In addition, representatives of this group of drugs reduce the risk of stroke, prevent the formation of blood clots, and slow down the disruption of blood supply and vascular damage.

During therapy, they are used both independently and in combination with other drugs, for example, with ACE inhibitors. These include: Verapamil, Devapamil, Diltiazem, Barnidipine, Clentiazem, Nifedipine.

Antagonist potassium

Diuretics

They remove excess sodium from the body and lower blood pressure, enhancing the effect of antihypertensive drugs. Long-term use diuretics are not advisable; if necessary, the dose of the drug should be minimal.

The use of diuretics as adjuncts is effective in the treatment of hypertension, heart failure and other diseases of cardio-vascular system. The following diuretics have proven themselves to be effective: Hypothiazide, Lasix, Uregit, Hydrochlorothiazide, Mannitol.

Angiotensin II receptor blockers

Such drugs can be used for patients with kidney diseases, joint diseases, diabetes mellitus, after myocardial infarction, strokes and others. associated complications.

Drugs such as “Candesartan-SZ”, “Valsartan”, “Eprosartan”, “Losartan” effectively stabilize high blood pressure, improve glucose levels, and prevent damage to the heart vessels by atherosclerosis. Sartans help reduce the amount of protein in the urine in patients with kidney diseases.

For the elderly

With age in human body processes that affect efficiency progress therapeutic measures that slow down the action medicines. The elasticity and tone of blood vessels decreases, they become more fragile, and in this condition it is difficult for them to adapt to a sharp change in pressure. The heart, brain, kidneys, organs of vision, and stomach are under attack.

Important! Selecting drugs for the treatment of arterial hypertension in the elderly must be done with caution, taking into account all age-related changes. The choice should be made on the most effective antihypertensive drugs with minimal side effects.

Among diuretics, the drug Indapamide retard is popular among elderly patients. Thanks to this remedy, blood pressure levels are stabilized and maintained at in good condition for a long time. Noted positive influence on general state elderly patient, reducing the likelihood of stroke.

Among calcium antagonists, there are “Verapamil” and “Diltiazem” with a short period of absorption and excretion from the body. Long-acting drugs include Lacidipine and Lercanidipine. Means strengthen nervous system, protect blood vessels and the heart, prevent the formation of blood clots.

During pregnancy

Arterial hypertension is one of the frequent cases complications that arise during pregnancy and lactation. The issue of managing pregnant women with this problem must be approached with special attention and caution, since such a condition of the expectant mother can harm the development of the fetus and cause growth retardation.

Pregnant women with this disease are at risk for developing placental abruption before the due date and spontaneous miscarriage.

Drugs for pregnant women

• up to 4 months - in order to find out the reasons for the increase in pressure, determine possible treatment;
• 5-6 months - during active growth fetus and maximum load on the maternal body. To adjust methods of antihypertensive therapy;
• 8 - 8.5 months - to prepare a woman for childbirth and determine the method of delivery.

Regardless of this scheme, if a pregnant woman’s blood pressure exceeds 160/110 mm Hg. Art., gynecologists recommend hospitalization in medical institution.

Important! When prescribing antihypertensive therapy to pregnant women, it should be taken into account that none of the existing funds is not absolutely harmless to the fetus.

If a woman had such problems before and took medications to lower blood pressure, then during pregnancy they are gradually discontinued and replaced with safer ones that are not contraindicated for the baby.

Drugs that do not pose a threat to the fetus, the use of which is permitted in the 1st trimester of pregnancy: Aspirin (40-150 mg per day); "Calciferol" (400 IU per day); "Calcium carbonate"; "Methyldopa"; "Hypothiazide" (12.5-25 mg per day).

If treatment with Methyldopa has not brought results, calcium antagonists are prescribed instead or in addition to it: Nifedipine retard, Amlodipine, Verapamil retard.

If there is no effect after using these drugs, selective blockers such as Bisoprol and Metoprolol are used. These medications are classified as hazardous to the health of mother and child. They are prescribed in exceptional cases when therapeutic effect from their use exceeds the risk of impaired fetal development or damage.

In the postpartum period and during lactation, it is necessary to adhere to the same regimen and sequence of medications that are recommended for antihypertensive therapy in pregnant women.

After bringing blood pressure to normal levels, regular consultations with the attending physician are necessary to monitor the course of the disease - depending on the existing complications, but at least 4 times a year.

Federal State Budgetary Institution "Educational and Scientific Medical Center" of the Administration of the President of the Russian Federation, Moscow

The literature review presents current understanding of the relationship between cognitive dysfunction and major risk factors and adverse cardiovascular outcomes. The main approaches to antihypertensive therapy for primary and secondary prevention of stroke, as well as the prevention of vascular dementia, are analyzed. The effectiveness of the angiotensin receptor blocker olmesartan in the treatment of arterial hypertension is examined in detail. Evidence of its angioprotective and cerebroprotective properties is presented. They allow us to recommend the drug primarily for the treatment of elderly patients with arterial hypertension, for whom the task of preserving cognitive functions is one of the priorities.
Keywords: olmesartan, arterial hypertension, cognitive function, dementia, stroke.

Rational Antihypertensive Treatment as Basis for Cerebral Protection and Cognitive Decline Prevention

L.O. Minushkina

Educational and Science Medicine Center of RF President Administration Department for Property Management, Moscow

The review of literature presents modern concepts of the relationship between cognitive decline and major cardiovascular risk factors, adverse cardiovascular outcomes. Basic approaches to antihypertensive therapy for primary and secondary prevention of stroke and vascular dementia are described. The article details the effectiveness of angiotensin receptor blocker called olmesartan in the treatment of hypertension. The drug presents vascular and cerebral protective properties; so olmesartan should be used primarily in elderly patients with hypertension in order to maintain cognition.
Keywords: olmesartan, hypertension, cognition, dementia, stroke.

Cognitive decline is a very significant risk factor for adverse outcomes. In a large study that included more than 30,000 patients followed for about 5 years, it was shown that the presence of dementia is associated with the risk of stroke, heart failure, and cardiovascular mortality. A decrease in Mini-Mental State Examination (MMSE) score of less than 24 was similar to stroke in its effect on the risk of recurrent events. The association of cognitive dysfunction with other adverse outcomes is due to the fact that dementia may be a marker of the severity of end-organ damage. In addition, patients with dementia are characterized by low adherence to treatment. Patients with decreased cognitive functions have lifestyle features associated with limited physical activity, dietary patterns, and the frequent development of mental depression. All this contributes to the progression of vascular diseases. Arterial hypertension (AH) is one of the leading risk factors for the development of progressive forms of cerebrovascular pathology and the formation of cognitive impairment.

Antihypertensive therapy is the basis for stroke prevention

For most patients, a reduction in the risk of complications is achieved by reducing blood pressure (BP) to 140/90 mm Hg. Art. The same blood pressure level is considered as a target for secondary prevention of strokes. Achieving lower blood pressure levels does not improve the prognosis of these patients. For elderly patients with hypertension, an even higher level of systolic blood pressure is considered as a target - 150 mmHg. When lowering blood pressure in these groups of patients, it is especially important to consider treatment tolerability.

In a meta-analysis of the largest studies on secondary prevention of stroke in patients who suffered an ischemic, hemorrhagic stroke or transient ischemic attack, it turned out that the success of secondary prevention depends primarily on the level of systolic blood pressure achieved during treatment. The overall risk reduction for recurrent stroke was 24%. However, there were differences in the effectiveness of different classes of antihypertensive drugs. The use of thiazide diuretics, and especially the combination of the latter with ACE inhibitors, allowed a more significant reduction in the risk of adverse outcomes than antihypertensive therapy with beta-blockers. One of the most well-known studies demonstrating the effectiveness of antihypertensive therapy in secondary stroke prevention was the PROGRESS study (Perindopril protection against recurrent stroke study), which showed a 28% reduction in the risk of recurrent stroke in the active treatment group (patients received perindopril as monotherapy and in combination with indapamide). In the group receiving only perindopril, blood pressure decreased by 5/3 mmHg. Art., and there was no significant reduction in the risk of stroke compared with the placebo group. In patients receiving combination therapy with perindopril and indapamide, the decrease in blood pressure was more significant - 12/5 mm Hg. Art., and the risk of stroke decreased by 46%, which was significant compared with placebo. The effectiveness of antihypertensive therapy in the secondary prevention of stroke has been shown in a number of other studies, such as PATS, ACCESS.

In the primary prevention of stroke in patients with arterial hypertension, the degree of reduction in blood pressure is also most significant for prognosis. When target blood pressure values ​​are achieved, the risk of stroke decreases by 40%. In patients with a predominant increase in diastolic blood pressure, its decrease by 5–6 mm Hg. Art. leads to a 40% reduction in the risk of stroke. In patients with isolated systolic arterial hypertension, lowering systolic blood pressure reduces the risk of cerebrovascular accidents by 30%. Significant factors also include the use of statins, therapy with ACE inhibitors, and endarterectomy in patients with hemodynamically significant stenoses of the coronary arteries. The use of aspirin reduces the risk of stroke in patients at high cardiovascular risk. In patients with low and moderate risk of complications, aspirin use did not reduce the risk of stroke.

Until recently, the question of the effectiveness of antihypertensive therapy in patients of older age groups remained open. The HYVET study, specifically designed to evaluate the effectiveness of treatment in patients with arterial hypertension over 80 years of age, showed that combination antihypertensive therapy reduced the risk of stroke by 39%.

There is evidence of possible cerebroprotective properties of angiotensin receptor blockers. Thus, the SCOPE study showed that in patients with arterial hypertension over the age of 70 years, treatment with the angiotensin receptor blocker candesartan significantly reduced the risk of non-fatal strokes. Particularly significant was the reduction in the risk of stroke when treated with angiotensin receptor blockers in patients with isolated systolic hypertension. This is confirmed by the results of the LIFE study, where in patients with ISAH, losartan reduced the risk of stroke by 40%, and the SCOPE study, where a 42% reduction in the risk of stroke was achieved in this subgroup.

The mechanism by which angiotensin receptor blockers have cerebroprotective properties is associated with the effect of stimulation of type 2 angiotensin receptors. It is this type of receptor that is expressed in the central nervous system. Their stimulation leads to a significant increase in cerebral blood flow. When treated with selective blockers of type 1 angiotensin receptors, there is an increase in the plasma level of angiotensin II, which, acting on type 2 receptors, creates conditions for cerebroprotection.

Prevention of vascular dementia

One of the most common manifestations of chronic cerebrovascular disease is vascular dementia. However, data on the relationship between the progression of vascular dementia and blood pressure levels and the effectiveness of antihypertensive therapy are contradictory. An increase in blood pressure is a factor contributing to the progression of atherosclerotic vascular damage, causing prothrombotic changes, and on the other hand, it is a compensatory reaction associated with impaired autoregulation of cerebral circulation. The relationship between the progression of vascular dementia and blood pressure levels is nonlinear. In addition, the severity of cognitive impairment is also influenced by the presence of other concomitant diseases and conditions - dyslipidemia, diabetes mellitus. It should be noted that a stroke itself is one of the most significant factors leading to the development of dementia. It is recorded in 10% of patients after the first stroke and in 30% of patients with repeated strokes. This increases the importance of stroke prevention as an opportunity to prevent the onset of severe cognitive impairment.

The effectiveness of antihypertensive therapy in preventing cognitive impairment has been studied in several large randomized trials. The Syst-Euro study showed that nitrendipine therapy can reduce the incidence of vascular dementia by 50%. In the PROGRESS study, the incidence of vascular dementia in the group receiving perindopril (as monotherapy and in combination with indapamide) decreased by 19%. On the other hand, in studies such as SHEP, SCOPE, HYVET-COG, therapy did not affect the incidence of cognitive impairment.

Angiotensin receptor blockers help prevent the development of cognitive dysfunction. This was shown in a large meta-analysis including data from the ONTARGET and TRANSDENT studies. Treatment with drugs of this group made it possible to reduce the risk of developing vascular dementia by 10% with long-term treatment.

It is interesting to note that, according to meta-analyses, with a small decrease in blood pressure (by 4.6/2.7 mm Hg), there is an improvement in short-term memory test scores. In studies where a more significant reduction in blood pressure was achieved (by 17/10 mm Hg), test performance worsened.

Tactics for lowering blood pressure to prevent cerebrovascular complications

It should be noted that the choice of a particular drug is most often not fundamentally important. In most patients, in order to achieve target blood pressure values, it is necessary to resort to combination therapy with two, three or more drugs from different groups. Monotherapy may be justified as a starting therapy in patients with grade 1 hypertension and a low or moderate risk of complications. In patients with grade 2–3 arterial hypertension who have a high or very high additional risk of complications, treatment can begin immediately using combination therapy.

It should be noted that patients with cerebrovascular disease and elderly patients do not always tolerate such a decrease in blood pressure well. When selecting therapy, it is necessary to take into account individual tolerance and avoid episodes of hypotension. In this case, it is necessary to take into account age-related characteristics, in particular, the optimal value of systolic blood pressure for the elderly is usually 135–150 mm Hg. Art., its further decrease leads to a worsening of the clinical picture of cognitive dysfunction and an increased risk of developing ischemic stroke. Particular care should be taken to reduce blood pressure in patients with hemodynamically significant atherosclerosis of the carotid arteries. As one of the control methods that facilitates the selection of therapy, 24-hour blood pressure monitoring can be used. This method allows you to control blood pressure at night, the speed and magnitude of the morning rise in blood pressure, and the presence of episodes of excessive hypotension. When analyzing all parameters of 24-hour blood pressure monitoring, it turned out that the level of systolic blood pressure at night has the greatest prognostic significance for the risk of stroke.

For the prevention of cerebrovascular events, the ability of drugs to influence the condition of the vascular wall and influence central pressure is also essential. The significance of these effects was demonstrated in the CAFE study conducted as part of the ASCOT project. The combination of amlodipine and perindopril has been shown to reduce central aortic pressure to a greater extent than treatment with atenolol and bendroflumethiazide. As is known, central blood pressure is closely related to the stiffness/elasticity of the vascular wall and pulse wave speed, which, in turn, can affect the occurrence of cardiovascular events, especially stroke.

The combination of a renin-angiotensin system blocker (ACE inhibitor or angiotensin receptor blocker) with a calcium antagonist or thiazide diuretic seems to be the most rational and pathogenetically substantiated today. A combination of two drugs in full doses does not normalize blood pressure in 10–20% of patients. If it is necessary to combine three antihypertensive drugs, a combination of a renin-angiotensin system blocker, a thiazide diuretic, or a calcium antagonist is preferable.

In elderly patients, drugs from the group of angiotensin receptor blockers have certain advantages. This group of antihypertensive drugs is characterized by cerebroprotective properties, as well as very good tolerability, low risk of side effects, which leads to good adherence of patients to treatment. One of the drugs in this group is olmesartan (KardosalR, Berlin-Chemie/A. Menarini), which has shown good efficacy in elderly patients, angio- and cerebroprotective properties.

Efficacy of olmesartan in the elderly

Olmesartan medoxomil is rapidly absorbed into the gastrointestinal tract after oral administration. The bioavailability of the drug is 26–28%, 35–50% of the dose is excreted unchanged by the kidneys, the rest with bile. The pharmacokinetics of olmesartan in elderly and young patients is not significantly different. In the treatment of hypertension, the drug is prescribed at a dose of 10–40 mg per day in a single dose regimen.

A meta-analysis of randomized trials using angiotensin receptor blockers, which included 4892 patients treated with olmesartan, showed that the reduction in blood pressure during therapy with olmesartan was more significant than during therapy with losartan and valsartan. At the same time, the tolerability of olmesartan is no worse than that of other sartans.

The effectiveness of olmesaratan in elderly patients was assessed in two studies of similar design. A total of 1646 patients over 65 years old participated in them. In one study, the effectiveness of olmesartan was assessed in patients with isolated systolic hypertension, in the other - with systolic-diastolic hypertension. Olmesartan was prescribed at a dose of 20–40 mg/day. In patients with isolated systolic hypertension, after 12 weeks of therapy, systolic blood pressure decreased by 30 mm Hg. Art. with slight changes in diastolic blood pressure. After 24 weeks of therapy, blood pressure normalized in 62.5% of patients. The drug was well tolerated in patients aged 65-74 years, and in patients over 75 years of age.

In a meta-analysis of 2 randomized trials that compared the effectiveness of ramipril and olmesartan, data on the treatment of 1400 patients with hypertension of 1 and 2 degrees over the age of 65 years were analyzed. It turned out that olmesartan is more effective in lowering blood pressure. Olmesartan therapy creates a more stable antihypertensive effect throughout the day, independent of meal times. Both drugs were well tolerated.

Two identical studies (European and Italian) compared the effectiveness of ramipril and olmesartan in elderly patients. The dose of ramipril was titrated from 2.5 to 10 mg, olmesartan - from 10 to 40 mg. A total of 1453 patients participated in the studies. In 715 of them, the effectiveness of therapy was monitored using 24-hour blood pressure monitoring. The decrease in blood pressure was more pronounced during therapy with olmesartan - the difference in the achieved level of systolic blood pressure was 2.2 mm Hg. Art., diastolic blood pressure – 1.3 mm Hg. Art. Olmesartan produced a significantly more pronounced decrease in blood pressure in the last 6 hours before taking the next dose. The smoothness index of blood pressure reduction was also higher in the olmesartan group. Only with treatment with this drug was there a significant decrease in the rate of morning increase in blood pressure; in the ramipril group there were no such dynamics. Thus, olmesartan was more effective in the elderly. It has been shown that with long-term therapy in patients with hypertension, olmesartan not only leads to a persistent decrease in blood pressure, but also helps to reduce pressure variability and improves the state of autonomic regulation of vascular tone.

The 735 patients in this study had metabolic syndrome and were analyzed separately for drug efficacy. In general, in the group, normalization of blood pressure was achieved in 46% of patients in the olmesartan group and in 35.8% of patients in the ramipril group. The same patterns were observed in groups of patients both with and without metabolic syndrome. Among elderly patients with metabolic syndrome, during therapy with olmesartan, the average daily systolic blood pressure decreased by 10.2 mm Hg. Art. and diastolic blood pressure – by 6.6 mm Hg. Art., and against the background of the prescription of ramipril - by 8.7 and 4.5 mm Hg. Art. respectively. The incidence of side effects was similar with both drugs.

Olmesartan is also effective in combination therapy. The Japanese study of olmesartan in the elderly (Miyazaki Olmesartan Therapy for Hypertension in the Elderly - MOTHER) compared the effectiveness of olmesartan in patients with hypertension in combination with a calcium antagonist and a thiazide diuretic. The combination with a calcium antagonist was slightly more effective in patients with normal body weight, and the combination with a thiazide diuretic had minor benefits in overweight patients. Blood creatinine levels remained stable throughout the 6 months of treatment. In the group of patients with normal body weight, regardless of the type of treatment, there was a significant decrease in blood aldosterone activity, which was not detected in obese patients.

In elderly patients, the combination of olmesartan and hypothiazide has been shown to be highly effective. The antihypertensive efficacy of a combination of 40 mg olmesartan and 25 mg hypothiazide was studied in a group of 176 patients with hypertension over 65 years of age. 116 patients had grade 1 hypertension, 60 patients had grade 2 hypertension, 98 patients had isolated systolic hypertension. Titration of antihypertensive therapy was carried out according to the regimen of olmesartan 20 mg daily, then 40 mg per day, combination with hypothiazide 12.5 mg, then 25 mg. Combination therapy was required in 159 patients. Normalization of blood pressure during treatment was achieved in 88% of patients with grade 1 hypertension, in 56% of patients with grade 2 hypertension, and in 73% of patients with isolated systolic hypertension. Daily blood pressure monitoring showed a sufficient duration of the antihypertensive effect when taking the combination once a day. The incidence of side effects associated with hypotension did not exceed 3%.

Angioprotective effects of olmesartan

Olmesartan is able to inhibit the progression of atherosclerotic vascular lesions, as was shown in the large randomized study MORE (The Multicentre Olmesartan atherosclerosis Regression Evaluation study). The study compared the effects of olmesartan and atenolol on carotid intima-media thickness and atherosclerotic plaque volume. Olmesartan was prescribed at a dose of 20–40 mg/day, atenolol – 50–100 mg/day. Examination of the carotid arteries using 2- and 3-dimensional ultrasound was carried out at 28, 52 and 104 weeks of treatment. The thickness of the intima-media complex of the carotid arteries decreased in both groups; there were no significant differences between groups. The decrease in the volume of atherosclerotic plaques was more significant during therapy with olmesartan, and in the group of patients whose initial lesion volume was greater than the group median, the differences in the effectiveness of the drugs were significant.

The angioprotective effect of olmesartan was also shown in a comparative study with the dihydropyridine calcium antagonist amlodipine. Patients with hypertension and diabetes mellitus received either 20 mg of olmesartan or 5 mg of amlodipine for a year. With the same antihypertensive effect, olmesartan also contributed to a significant decrease in the cardio-ankle index, which reflects the severity of arterial stiffness. The authors of the study associate the angioprotective effect of olmesartan with its antioxidant properties.

A decrease in central pressure during treatment with olmesartan has also been shown. The combination of olmesartan with dihydropyridine calcium antagonists is particularly effective. A randomized trial compared the effects of the two combinations on central blood pressure. 486 patients were allocated to treatment with olmesartan and amlodipine at a dose of 40/10 mg or perindopril and amlodipine at a dose of 8/10 mg. Central systolic pressure decreased by 14.5 mm Hg when taking the first combination, and by 10.4 mm Hg when using the second combination. Art. The differences between the groups turned out to be significant. In the olmesartan group, normalization of blood pressure was achieved in 75.4% of patients, and in 57.5% of patients treated with perindopril. .

In combination therapy, the combination of olmesartan with a dihydropyridine calcium antagonist is more effective in reducing central pressure in the aorta than the combination of olmesartan and a thiazide diuretic. The decrease in pressure on the brachial artery was the same.

The basis for the angioprotective effect of olmesartan may be its effect on the processes of peroxidation, the function of the vascular endothelium, the level of inflammatory mediators, and some biomarkers. The antioxidant effect of olmesartan was demonstrated in a small study where 20 patients with hypertension received therapy with olmesartan at a dose of 20 mg/day for 6 months. The drug was effective and allowed to normalize blood pressure in all patients. At the same time, the level of markers of oxidative stress and oxidized lipoproteins, as well as markers of inflammation, significantly decreased.

In a comparative study on a group of 31 patients with hypertension, the effectiveness of olmesartan and amlodipine was compared. Both drugs were equally effective in lowering blood pressure, but only with olmesartan were there signs of improved endothelial function. Only treatment with olmesartan improved the degree of reactive hyperemia. In the same group, a decrease in the level of albuminuria and a decrease in C-reactive protein were recorded. The level of urine antioxidants increased. The dynamics of the plasma level of superoxide disumutase were not revealed, but there was a correlation between the level of this antioxidant defense enzyme and the degree of endothelium-dependent vasodilation.

In a group of 30 patients with hypertension, the effects of long-term (6 months) therapy with olmesartan at a dose of 20 mg/day were assessed. Olmesartan effectively lowered blood pressure and contributed to a significant decrease in the cardio-ankle index, which reflects the stiffness of the arterial wall. The level of C-reactive protein and adipocyte fatty acid binding protein significantly decreased.

All these angioprotective properties create the prerequisites for the effectiveness of olmesartan in the prevention of vascular dementia and cerebral stroke.

Cerebroprotective properties of olmesartan

The basis for the cerebroprotective effect of olmesartan may be its effect on the state of cerebral blood flow. This was shown in a study where a group of elderly patients with hypertension without signs of central nervous system damage in the anamnesis received olmesartan for 24 months. Initially, a decrease in regional blood flow in the frontal, parietal, temporal and occipital lobes was shown by 11–20% compared to the control group, which included age-matched individuals who did not have hypertension. At baseline, in the group of patients with hypertension, the average blood pressure was 156/88 mm Hg. Art., and during treatment with olmesartan – 136/78 mm Hg. Art. At the same time, at the end of treatment, the indicators of regional cerebral blood flow did not differ from the blood flow indicators in the control group.

In a group of patients who had suffered a stroke, the effectiveness of olmesartan therapy at a dose of 10–20 mg per day for 8 weeks was assessed. During treatment, patients showed a significant improvement in the state of regional cerebral blood flow. The increase in cerebral blood flow in the affected area was 11.2%, in the contralateral zone – 8.9%. The state of autoregulation of tone has improved cerebral vessels. Ultimately, this led to improved rehabilitation processes for patients after stroke and a reduction in neurological deficits. An improvement in the patients' condition was recorded according to the Bartels index and the MMSE scale. When comparing the effectiveness of therapy with olmesartan and amlodipine in patients after stroke, it turned out that with the same effect on peripheral blood pressure, only olmesartan therapy improved cerebral blood flow. Only in the group receiving olmesartan after a stroke, there was an increase in cerebral blood flow both on the affected side and in the healthy hemisphere, as well as an increase in cerebrovascular reserve. The range of movements in the hand increased by 30%, the arm – by 40%, and the leg – by 100%. At the same time, the increase in movements in the arm and leg was significantly greater than during amlodipine therapy. The Bartels index and MMSE also increased.

Thus, olmesartan not only has good antihypertensive efficacy, the ability to reduce arterial stiffness, and improve vascular endothelial function, but also has cerebroprotective properties. This allows us to recommend the drug primarily for the treatment of elderly patients with hypertension, for whom the task of preserving cognitive functions is one of the priorities.

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Different doctors may have their own treatment regimen. However, there are general concepts based on statistics and research.

At the initial stage

In uncomplicated cases, drug antihypertensive therapy is often started with the use of proven “conventional” drugs: beta-blockers and diuretics. Large-scale studies involving patients have shown that the use of diuretics and beta-blockers reduces the risks of cerebrovascular accidents, sudden death, and myocardial infarction.

An alternative option is the use of captopril. According to new data, the incidence of heart attacks, strokes, and deaths when using conventional treatment or using captopril is almost the same. Moreover, in a special group of patients who had not previously been treated with antihypertensive drugs, captopril showed a clear advantage over conventional therapy, significantly reducing the relative risk of cardiovascular events by 46%.

Long-term use of fosinopril in patients with diabetes, as well as arterial hypertension, is also associated with a significant reduction in the risk of death, myocardial infarction, stroke, and exacerbation of angina.

Therapy for left ventricular hypertrophy

Many doctors use angiotensin-converting enzyme (ACE) inhibitors as antihypertensive therapy. These drugs have cardioprotective properties and lead to a decrease in the mass of the LV myocardium (left ventricle). When studying the degree of impact of various drugs on the LV myocardium, it was revealed that the reverse degree of development of its hypertrophy is most pronounced in ACE inhibitors, since antiotensin-2 controls the growth, hypertrophy of cardiomyocytes and their division. In addition to cardioprotective effects, ACE inhibitors have nephroprotective effects. This is important, because despite all the successes of antihypertensive therapy, the number of patients who develop end-stage renal failure is growing (4 times compared to the “eighties”).

Calcium antagonist therapy

Calcium antagonists are increasingly used as first-line drugs. For example, long-acting dihydropyridine calcium channel blockers are effective for isolated systemic arterial hypertension (AH). A four-year study of 5,000 patients showed a significant effect of nitrendipine on the incidence of cerebral stroke. In another study, the base drug was a long-acting calcium antagonist, felodipine. Patients were observed for four years. As BP (blood pressure) decreased, the beneficial effects increased, the risk of cardiovascular complications decreased significantly, and the incidence of sudden death did not increase. The SystEur study, which involved 10 Russian centers, also showed a 42% reduction in the incidence of strokes with the use of nisoldipine.

Calcium antagonists are also effective for pulmonary arterial hypertension (this is systemic hypertension that occurs in patients with obstructive pulmonary diseases). Pulmonogenic hypertension develops several years after the onset of a pulmonary disease, and there is a clear connection between the exacerbation of the pulmonary process and increases in pressure. The advantage of calcium antagonists in pulmonary hypertension is that they reduce calcium ion-mediated hypoxic vasoconstriction. The delivery of oxygen to tissues increases, hypoxia of the kidneys and vasomotor center decreases, blood pressure decreases, as well as afterload and myocardial oxygen demand. In addition, calcium antagonists reduce the synthesis of histamine, kinin, serotonin in tissues, swelling of the bronchial mucosa and bronchial obstruction. An additional advantage of calcium antagonists (in particular, isradipine) is their ability to change metabolic processes in patients with hypertension. By normalizing or reducing blood pressure, these drugs can prevent the development of dyslipidemia, glucose and insulin tolerance.

For calcium antagonists, a clear relationship has been identified between dose, plasma concentration and pharmacological hypotensive effect. By increasing the dose of the drug, you can, as it were, control the hypotensive effect, increasing or decreasing it. For long-term treatment of hypertension, long-acting drugs with a low absorption rate are preferred (amlodipine, a long-acting gastrointestinal form of nifedipine, or osmoadolate, a long-acting form of felodipine). When using these drugs, smooth vasodilation occurs without reflex activation of the sympathetic-adrenal system, release of catecholamines, reflex tachycardia and increased myocardial oxygen demand.

Myotropic vasodilators, central alpha-2-adrenergic agonists, and peripheral adrenergic agonists are not recommended as first-choice drugs, taking into account tolerability.

Antihypertensive drugs: principles of therapy, groups, list of representatives

Antihypertensive drugs (antihypertensives) include a wide range of medications designed to lower blood pressure. Since about the middle of the last century, they began to be produced in large volumes and widely used in patients with hypertension. Until this time, doctors only recommended diet, lifestyle changes and sedatives.

Arterial hypertension (AH) is the most commonly diagnosed disease of the cardiovascular system. According to statistics, approximately every second elderly person on the planet has signs of high blood pressure, which requires timely and correct correction.

To prescribe drugs that lower blood pressure (BP), it is necessary to establish the very presence of hypertension, assess the possible risks for the patient, contraindications to specific medications and the feasibility of treatment in principle. The priority of antihypertensive therapy is to effectively reduce blood pressure and prevent possible complications of a dangerous disease, such as stroke, myocardial infarction, and renal failure.

The use of antihypertensive drugs has reduced mortality from severe forms of hypertension over the past 20 years by almost half. The optimal level of pressure that should be achieved with the help of treatment is considered to be a figure not exceeding 140/90 mmHg. Art. Of course, in each case, the need for therapy is decided individually, but in case of prolonged high blood pressure, the presence of damage to the heart, kidneys, or retina, it should be started immediately.

According to the recommendations of the World Health Organization, diastolic pressure of 90 mmHg or higher is considered an absolute indication for antihypertensive therapy. Art., especially if such a figure lasts for several months or six months. Usually medications are prescribed for an indefinite period, for most patients - for life. This is due to the fact that when therapy is discontinued, three quarters of patients experience symptoms of hypertension again.

Many patients are afraid of long-term or even lifelong use of medications, and often the latter are prescribed in combinations that include several items. Of course, concerns are understandable, because any medicine has side effects. Numerous studies have proven that there is no health risk with long-term use of antihypertensive drugs, side effects are minimal, provided the dose and dosage regimen are correctly selected. In each case, the doctor individually determines the specifics of treatment, taking into account the form and course of hypertension, contraindications, and concomitant pathology in the patient, but it is still necessary to warn about possible consequences.

Principles of prescribing antihypertensive therapy

Thanks to many years of clinical studies involving thousands of patients, the basic principles of drug treatment of arterial hypertension were formulated:

• Treatment begins with the smallest doses of the drug, using a medicine with a minimum of side effects, that is, choosing the safest remedy.
• If the minimum dose is well tolerated, but the blood pressure level is still high, then the amount of medication is gradually increased to what is necessary to maintain normal blood pressure.
• To achieve the best effect, it is recommended to use combinations of drugs, prescribing each of them in the lowest possible dosages. Currently, standard combination treatment regimens for hypertension have been developed.
• If the second prescribed drug does not give the desired result or its use is accompanied by side effects, then it is worth trying a drug from another group, without changing the dosage and regimen of the first drug.
• Long-acting drugs are preferable, allowing you to maintain normal blood pressure throughout the day, without allowing fluctuations, which increase the risk of complications.

Antihypertensive drugs: groups, properties, features

Many drugs have antihypertensive properties, but not all of them can be used to treat patients with hypertension due to the need for long-term use and the possibility of side effects. There are five main groups of antihypertensive drugs used today:

1. Angiotensin-converting enzyme inhibitors (ACEIs).
2. Angiotensin II receptor blockers.
3. Diuretics.
4. Calcium antagonists.
5. Beta blockers.

Medicines from these groups are effective for arterial hypertension and can be prescribed as initial treatment or maintenance therapy, alone or in various combinations. When choosing specific antihypertensive drugs, the specialist is based on the patient’s blood pressure, the characteristics of the course of the disease, the presence of target organ damage, concomitant pathology, especially from the cardiovascular system. The overall probable side effect, the possibility of combining drugs from different groups, as well as existing experience in treating hypertension in a particular patient are always assessed.

Unfortunately, many effective drugs are not cheap, which makes them inaccessible to the general population. The cost of the drug may become one of the conditions under which the patient will be forced to abandon it in favor of another, cheaper analogue.

Angiotensin-converting enzyme inhibitors (ACEIs)

Drugs from the ACE inhibitor group are quite popular and are widely prescribed to a wide variety of patients with high blood pressure. The list of ACE inhibitors includes such drugs as: captopril, enalapril, lisinopril, Prestarium, etc.

As is known, blood pressure levels are regulated by the kidneys, in particular, by the renin-angiotensin-aldosterone system, the proper functioning of which determines the tone of the vascular walls and the final level of pressure. With an excess of angiotensin II, spasm of arterial type vessels in the systemic circulation occurs, which leads to an increase in total peripheral vascular resistance. To ensure adequate blood flow in the internal organs, the heart begins to work with excess load, pumping blood into the vessels under increased pressure.

In order to slow down the formation of angiotensin II from its precursor (angiotensin I), it was proposed to use drugs that block the enzyme involved in this stage of biochemical transformations. In addition, ACEIs reduce the release of calcium, which is involved in the contraction of vascular walls, thereby reducing their spasm.

mechanism of action of ACE inhibitors in CHF

Prescribing an ACEI reduces the likelihood of cardiovascular complications (stroke, myocardial infarction, severe heart failure, etc.), the degree of damage to target organs, especially the heart and kidneys. If the patient already suffers from chronic heart failure, then the prognosis of the disease improves when taking drugs from the ACEI group.

Based on the characteristics of the action, it is most rational to prescribe ACE inhibitors to patients with kidney pathology and chronic heart failure, with arrhythmias, after a heart attack; they are safe for use by the elderly and for diabetes mellitus, and in some cases can even be used by pregnant women.

The disadvantage of ACE inhibitors is that the most common adverse reactions are dry cough associated with changes in bradykinin metabolism. In addition, in some cases, the formation of angiotensin II occurs without a special enzyme, outside the kidneys, so the effectiveness of ACE inhibitors is sharply reduced, and treatment requires the choice of another drug.

The following are considered absolute contraindications to the use of ACE inhibitors:

• Pregnancy;
• Significant increase in potassium levels in the blood;
• Severe stenosis of both renal arteries;
• Quincke's edema with previous use of ACE inhibitors.

Angiotensin II receptor blockers (ARBs)

Drugs from the ARB group are the most modern and effective. Like ACEIs, they reduce the effect of angiotensin II, but, unlike the latter, their point of application is not limited to a single enzyme. ARBs act more broadly, providing a powerful antihypertensive effect by disrupting the binding of angiotensin to receptors on cells in various organs. Thanks to this targeted action, relaxation of the vascular walls is achieved, and the excretion of excess fluid and salt by the kidneys is enhanced.

The most popular ARBs are losartan, valsartan, irbesartan, etc.

Like ACEIs, drugs from the group of angiotensin II receptor antagonists show high efficiency with pathology of the kidneys and heart. In addition, they are practically free of adverse reactions and are well tolerated with long-term administration, which allows them to be widely used. Contraindications to ARBs are similar to those for ACE inhibitors - pregnancy, hyperkalemia, renal artery stenosis, allergic reactions.

Diuretics

Diuretics are not only the most extensive, but also the longest used group of drugs. They help remove excess fluid and salt from the body, thereby reducing the volume of circulating blood, the load on the heart and blood vessels, which ultimately relax. The classification involves the separation of groups of potassium-sparing, thiazide and loop diuretics.

Thiazide diuretics, including hypothiazide, indapamide, chlorthalidone, are not inferior in effectiveness to ACE inhibitors, beta blockers and other groups of antihypertensive drugs. High concentrations can lead to changes in electrolyte metabolism, lipid and carbohydrate metabolism, but low dosages of these drugs are considered safe even with long-term use.

Thiazide diuretics are used as part of combination therapy along with ACE inhibitors and angiotensin II receptor antagonists. They can be prescribed to elderly patients, people suffering from diabetes mellitus, and various metabolic disorders. Gout is considered an absolute contraindication to taking these drugs.

Potassium-sparing diuretics have a milder effect compared to other diuretics. The mechanism of action is based on blocking the effects of aldosterone (an antidiuretic hormone that retains fluid). A decrease in pressure is achieved by removing fluid and salt, but potassium, magnesium, and calcium ions are not lost.

Potassium-sparing diuretics include spironolactone, amiloride, eplerenone, etc. They can be prescribed to patients with chronic heart failure and severe edema of cardiac origin. These drugs are effective for refractory hypertension that is difficult to treat with other groups of drugs.

Due to their effect on renal aldosterone receptors and the risk of hyperkalemia, these substances are contraindicated in acute and chronic renal failure.

Loop diuretics (Lasix, Edecrine) act the most aggressively, but at the same time they can reduce blood pressure faster than others. They are not recommended for long-term use, since the risk of metabolic disorders is high due to the excretion of electrolytes along with fluid, but these drugs are successfully used for the treatment of hypertensive crises.

Calcium antagonists

The contraction of muscle fibers occurs with the participation of calcium. Vascular walls are no exception. Drugs from the group of calcium antagonists act by reducing the penetration of calcium ions into the smooth muscle cells of blood vessels. The sensitivity of blood vessels to vasopressor substances that cause vascular spasm (adrenaline, for example) also decreases.

The list of calcium antagonists includes drugs of three main groups:

1. Dihydropyridines (amlodipine, felodipine).
2. Benzothiazepine calcium antagonists (diltiazem).
3. Phenylalkylamines (verapamil).

The drugs of these groups differ in the nature of their effect on the walls of blood vessels, the myocardium, and the conduction system of the heart. Thus, amlodipine and felodipine act primarily on blood vessels, reducing their tone, while the work of the heart does not change. Verapamil, diltiazem, in addition to the hypotensive effect, affect the functioning of the heart, causing a decrease in heart rate and its normalization, therefore they are successfully used for arrhythmias. By reducing the oxygen demand of the heart muscle, verapamil reduces the pain syndrome of angina pectoris.

When prescribing non-dihydropyridine diuretics, possible bradycardia and other types of bradyarrhythmias must be taken into account. These medications are contraindicated in severe heart failure, atrioventricular blockade, and simultaneously with intravenous beta-blockers.

Calcium antagonists do not affect metabolic processes, reduce the degree of hypertrophy of the left ventricle of the heart in hypertension, and reduce the likelihood of stroke.

Beta blockers

Beta-blockers (atenolol, bisoprolol, nebivolol) have a hypotensive effect by reducing cardiac output and the formation of renin in the kidneys, causing vascular spasm. Due to their ability to regulate heart rhythm and have an antianginal effect, beta blockers are preferred for reducing blood pressure in patients suffering from coronary heart disease (angina pectoris, cardiosclerosis), as well as in chronic heart failure.

Beta-blockers change carbohydrate and fat metabolism and can provoke weight gain, so they are not recommended for diabetes mellitus and other metabolic disorders.

Substances with adrenergic blocking properties cause bronchospasm and slow heart rate, and therefore they are contraindicated for asthmatics, with severe arrhythmias, in particular, atrioventricular block of the II-III degree.

Other drugs with antihypertensive effects

In addition to the described groups of pharmacological agents for the treatment of arterial hypertension, additional drugs are successfully used - imidazoline receptor agonists (moxonidine), direct renin inhibitors (aliskiren), alpha-blockers (prazosin, cardura).

Imidazoline receptor agonists act on nerve centers in the medulla oblongata, reducing the activity of sympathetic stimulation of blood vessels. Unlike drugs from other groups, which at best do not affect carbohydrate and fat metabolism, moxonidine is able to improve metabolic processes, increase tissue sensitivity to insulin, and reduce triglycerides and fatty acids in the blood. Taking moxonidine in overweight patients promotes weight loss.

Direct renin inhibitors are represented by the drug aliskiren. Aliskiren helps reduce the concentration of renin, angiotensin, angiotensin-converting enzyme in the blood serum, providing a hypotensive, as well as cardioprotective and nephroprotective effect. Aliskiren can be combined with calcium antagonists, diuretics, beta-blockers, but simultaneous use with ACE inhibitors and angiotensin receptor antagonists is fraught with impaired renal function due to the similarity of pharmacological action.

Alpha-blockers are not considered drugs of choice; they are prescribed as part of combination treatment as a third or fourth additional antihypertensive agent. Medicines in this group improve fat and carbohydrate metabolism, increase blood flow in the kidneys, but are contraindicated in diabetic neuropathy.

The pharmaceutical industry does not stand still; scientists are constantly developing new and safe drugs to lower blood pressure. The latest generation of drugs can be considered aliskiren (Rasilez), olmesartan from the group of angiotensin II receptor antagonists. Among diuretics, torasemide has proven itself well, which is suitable for long-term use and is safe for elderly patients and patients with diabetes mellitus.

Combination drugs are also widely used, including representatives of different groups “in one tablet,” for example, Equator, which combines amlodipine and lisinopril.

Traditional antihypertensive drugs?

The described medications have a persistent hypotensive effect, but require long-term use and constant monitoring of blood pressure levels. Fearing side effects, many hypertensive patients, especially older people suffering from other diseases, prefer herbal remedies and traditional medicine to taking pills.

Antihypertensive herbs have a right to exist, many actually have a good effect, and their effect is mostly associated with sedative and vasodilating properties. Thus, the most popular are hawthorn, motherwort, peppermint, valerian and others.

There are ready-made mixtures that can be bought in the form of tea bags at the pharmacy. Evalar Bio tea, containing lemon balm, mint, hawthorn and other herbal ingredients, Traviata are the most famous representatives of herbal antihypertensive drugs. The hypotensive monastery tea has also proven itself quite well. At the initial stage of the disease, it has a restorative and calming effect on patients.

Of course, herbal infusions can be effective, especially in emotionally labile subjects, but it should be emphasized that self-treatment of hypertension is unacceptable. If the patient is elderly, suffers from cardiac pathology, diabetes, atherosclerosis, then the effectiveness of traditional medicine alone is questionable. In such cases, drug therapy is required.

In order for drug treatment to be more effective and drug dosages to be minimal, the doctor will first advise patients with arterial hypertension to change their lifestyle. Recommendations include smoking cessation, weight normalization, and a restricted diet table salt, liquids, alcohol. Adequate physical activity and the fight against physical inactivity are important. Non-drug measures to lower blood pressure can reduce the need for medications and increase their effectiveness.

Treatment of hypertension

The main risk factor for the development of the most serious vascular diseases (stroke and myocardial infarction) is well known - hypertension. The main method of treating hypertension is antihypertensive therapy, i.e. lowering elevated blood pressure values ​​with the help of medications without affecting the root cause of hypertension. Now there are many modern medications that help lower blood pressure. All these drugs are divided into classes depending on their mechanism of action.

Diuretics (diuretics) stimulate the excretory function of the kidneys, which helps the body get rid of excess fluid. These include arifon, hydrochlorothiazide, brinaldix, diuver, veroshpiron.

Adrenergic blockers (alpha blockers and beta blockers) reduce the effect of adrenaline on nerve receptors, thereby reducing the impact of stress factors on blood vessels. Among them are prazosin, doxazosin (alpha-blockers) and atenolol, propranalol, nadolol, concor (beta-blockers).

Prestarium drugs, captopril, enalapril, losartan and valsartan, inhibit the action of angiotensin-converting enzyme, which causes an increase in blood pressure. Centrally acting drugs (clonidine, tsint) and calcium antagonists (nifedipine, nimodipine, verapamil) can also lower blood pressure.

Unfortunately, all antihypertensive drugs have contraindications and side effects, so in most cases combination therapy using several drugs at once is indicated. It should be kept in mind that high blood pressure should be reduced gradually. A sharp drop in pressure can be no less dangerous than its increase. Often, an overdose of antihypertensive drugs can cause a very sharp decrease in blood pressure, which is dangerous in itself, especially for older people with altered blood vessels. Therefore, if blood pressure is consistently elevated, target values ​​should be reached gradually, no faster than after a few weeks. In addition, in most cases, you should not stop antihypertensive therapy without consulting a doctor, even if you have reached your target “normal” blood pressure values. Hypertension, as a rule, does not go away so easily: at any moment it can return and remind you of itself with the usual symptoms: headaches and heart pain, nausea, dizziness, after which, at best, you will have to start all over again.

Cardiology cheat sheet: antihypertensive therapy

Antihypertensive therapy in patients with liver dysfunction:

• first choice drugs: Verapamil, diltiazem; Nifedipine group;
• Second choice drugs: Diuretics.

First choice drugs for patients with arterial hypertension:

• and rhythm disturbances (sinus tachycardia, supraventricular, ventricular arrhythmias):
  • Cardioselective beta-blockers;
  • Central antagonists;
  • Verapamil;
  • Diltiazem.
• and rhythm disturbances (sinus bradycardia, sick sinus syndrome, AV block):
  • Nifedipine retard and other drugs in this group;
  • ACE inhibitors.
• • Diltiazem retard;
  • Verapamil retard;
  • Long-acting ACE inhibitors (enalapril).
• • ACE inhibitors;
  • Moderate diuretics (hypothiazide, indapamide, oxodoline).

Second choice drugs in patients with arterial hypertension:

• therapy, which should be carried out over a long period of time, in patients with severe dyslipidemia:
  • Cardioselective beta-blockers.
• and systolic form of chronic heart failure (CHF):
  • Loop diuretics (furosemide, uregit);
  • Dihydroperidine calcium antagonists (nifedipine retard, amlodipine);
  • Metoprolol.
  • Drugs that have the most pronounced hypotensive effect:
    • Calcium antagonists;
  • Drugs that do not worsen the quality of life and most effectively lower blood pressure:
    • Calcium antagonists;
    • ACE inhibitors;
    • Alpha1-blockers
  • Drugs that do not have a negative effect on other risk factors for the development of cardiovascular complications and are most effective in lowering blood pressure:
    • Calcium antagonists;
    • ACE inhibitors;
    • Alpha1-adrenergic blockers;
    • Central agonists;
    • Arteriolar vasodilators (apressin, minoxidine).

    ATTENTION! There may be an inaccurate or incorrect answer. Please check information from other sources, such as lecture notes.

    Hypotensive effect: what is it?

    Hypotensive effect - what is it? This question is asked by women and men who are faced with the problem of high blood pressure or hypertension for the first time and who have no idea what the hypotensive effect of the drugs prescribed to them by their attending physician means. An antihypertensive effect is a decrease in blood pressure under the influence of a particular drug.

    Experienced professional therapists of the highest category at the Yusupov Hospital Therapy Clinic, who are proficient in advanced treatment and diagnostic methods, will provide qualified assistance to patients with arterial hypertension and select an effective treatment regimen that eliminates the development of negative consequences.

    Antihypertensive therapy: general rules

    Both symptomatic hypertension and hypertension require correction with drugs that have a hypotensive effect. Antihypertensive therapy can be carried out with drugs that differ in their mechanism of action: antiadrenergic agents, vasodilators, calcium antagonists, angiotensin antagonists, and diuretics.

    You can obtain information about the hypotensive effect of the drug and what medications to take for high blood pressure not only from your doctor, but also from your pharmacist.

    Arterial hypertension is a chronic disease that requires constant drug support, daily monitoring and regular use of prescribed medications. Not only the state of health, but also the life of a person depends on compliance with these rules.

    Despite the general availability of treatment rules for reducing blood pressure, many patients have to be reminded what a treatment regimen for hypertension should look like:

    • Antihypertensive medications should be taken regularly, regardless of the patient’s well-being and blood pressure level. This allows you to increase the effectiveness of blood pressure control, as well as prevent cardiovascular complications and target organ damage;
    • It is necessary to strictly adhere to the dosage and use the form of the drug prescribed by the attending physician. Independently changing the recommended dose or replacing the drug may distort the hypotensive effect;
    • even if you are constantly taking antihypertensive drugs, it is necessary to systematically measure blood pressure, which will allow you to evaluate the effectiveness of therapy, timely identify certain changes and adjust treatment;
    • in the case of an increase in blood pressure against the background of constant antihypertensive treatment - the development of an uncomplicated hypertensive crisis, an additional dose of a previously taken long-acting drug is not recommended. Blood pressure can be quickly reduced using short-acting antihypertensive drugs.

    Antihypertensive therapy: drugs to lower blood pressure

    During antihypertensive therapy, several main groups of drugs that help lower blood pressure are currently used:

    • beta blockers;
    • ACE inhibitors;
    • calcium antagonists;
    • diuretics;
    • angiotensin II receptor blockers.

    All of the above groups have comparable effectiveness and their own characteristics that determine their use in a given situation.

    Beta blockers

    Drugs in this group reduce the likelihood of developing coronary complications in patients suffering from angina pectoris, prevent cardiovascular accidents in patients with myocardial infarction, tachyarrhythmia, and are used in patients with chronic heart failure. Beta-blockers are not recommended for patients with diabetes mellitus, lipid metabolism disorders and metabolic syndrome.

    ACE inhibitors

    Angiotensin-converting enzyme inhibitors have pronounced hypotensive properties, they have organoprotective effects: their use reduces the risk of complications of atherosclerosis, reduces left ventricular hypertrophy, and slows the decline in renal function. ACE inhibitors are well tolerated and have no negative effects on lipid metabolism and glucose levels.

    Calcium antagonists

    In addition to antihypertensive properties, drugs in this group have antianginal and organoprotective effects, help reduce the risk of strokes, atherosclerotic lesions of the carotid arteries and left ventricular hypertrophy. Calcium antagonists may be used alone or in combination with other drugs that have antihypertensive properties.

    Diuretics

    Diuretic drugs are usually used in combination with other antihypertensive drugs in order to enhance the therapeutic effect.

    Diuretics are also prescribed to persons suffering from pathologies such as refractory hypertension and chronic heart failure. To avoid the development of side effects, when taking these drugs continuously, minimal dosages are prescribed.

    Angiotensin II receptor blockers

    Drugs in this group, which have neuro- and cardioprotective effects, are used to improve control of blood glucose levels. They can increase the life expectancy of patients suffering from chronic heart failure. Antihypertensive therapy using angiotensin II receptor blockers can be prescribed to patients who have had a myocardial infarction, suffer from renal failure, gout, metabolic syndrome and diabetes mellitus.

    Antihypertensive therapy for hypertensive crisis

    Even despite constant antihypertensive therapy, a sudden increase in blood pressure to fairly high levels may periodically occur (there are no signs of target organ damage). The development of an uncomplicated hypertensive crisis can be caused by unusual physical activity, emotional stress, consumption of alcohol or salty, fatty foods. This condition is not life-threatening, but it threatens the development of negative consequences, and therefore requires timely treatment.

    A too rapid decrease in blood pressure is undesirable. It is optimal if in the first two hours after taking the drug the pressure decreases by no more than 25% of the initial values. Normal blood pressure values ​​are usually restored within 24 hours.

    Rapid-acting medications help restore blood pressure control, providing an almost immediate hypotensive effect. Each of the drugs for quickly lowering blood pressure has its own contraindications, so a doctor should select them.

    30 minutes after taking an antihypertensive drug, it is necessary to measure blood pressure to assess the effectiveness of therapy. If necessary, in order to restore normal blood pressure levels, after half an hour or an hour you can take an additional tablet (orally or sublingually). If there is no improvement (pressure decrease by less than 25% or its previous excessively high levels), you should immediately seek the help of a doctor.

    In order to prevent arterial hypertension from becoming chronic, accompanied by quite serious complications, it is necessary to pay attention to the first signs of arterial hypertension in time. You should not self-medicate and randomly select drugs that reduce blood pressure. Despite their hypotensive effect, they can have a lot of contraindications and be accompanied by side effects that aggravate the patient's condition. The selection of medications for antihypertensive therapy should be carried out by a qualified specialist familiar with the characteristics of the patient’s body and his medical history.

    The Therapy Clinic of the Yusupov Hospital offers a comprehensive approach to eliminating problems associated with high blood pressure.

    The clinic has the latest modern diagnostic and treatment equipment from world leaders - manufacturers of medical equipment, which allows us to identify the first manifestations of hypertension at the earliest diagnostic level and select the most effective methods for treating the disease. When drawing up a treatment regimen, the patient’s age, condition and other individual factors are taken into account.

    Conservative therapy at the Yusupov Hospital involves the use of the latest generation drugs that have minimal side effects. Consultations are conducted by highly qualified therapists with extensive treatment experience. hypertension and its consequences, including stroke.

    You can make an appointment with the clinic’s leading specialists by phone or on the Yusupov Hospital website using the feedback form.

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    Antihypertensive therapy: what you need to know?

    Arterial hypertension is one of those chronic diseases that require constant drug support, daily monitoring and regular use of prescribed medications. Not only the well-being, but also the life of the sick person directly depends on how carefully the rules of antihypertensive therapy are followed.

    Not only the attending physician, but also the pharmacist advising a visitor to the pharmacy can tell you how to properly treat arterial hypertension, what medications are used and in what cases.

    General rules of therapy

    The rules of antihypertensive therapy are simple and well-known, but many patients often neglect them, and therefore it would not be amiss to once again remind what treatment of hypertension should be.

    1. Antihypertensive drugs are taken constantly. Regardless of whether a person feels bad or good, whether blood pressure (BP) is elevated or remains normal, drug therapy should be constant. Only with daily intake of antihypertensive drugs can blood pressure levels be effectively controlled and target organ damage and cardiovascular complications avoided.
    2. Antihypertensive drugs are taken in the dosage and release form in which they are prescribed by the doctor. You should not change the recommended dose yourself or try to replace one drug with another, because this may negatively affect the hypotensive effect.
    3. Even with constant use of antihypertensive drugs, blood pressure should be measured regularly, at least 2 times a week. This is necessary to monitor the effectiveness of therapy, allows you to timely notice changes occurring in the body and adjust treatment.
    4. If, against the background of constant antihypertensive therapy, blood pressure suddenly increases, i.e. An uncomplicated hypertensive crisis develops; it is not recommended to take an additional dose of the patient’s usual drug. For continuous use, long-acting drugs are prescribed, the effect of which develops gradually. To quickly reduce blood pressure, a hypertensive patient's home medicine cabinet must contain short-acting antihypertensive drugs.

    Features of different groups of drugs

    For the treatment of arterial hypertension, 5 main groups of antihypertensive drugs are used today: ACE inhibitors, beta-blockers, diuretics, calcium antagonists and angiotensin II receptor blockers. All of them have comparable effectiveness, but each group has its own characteristics that determine the use of these drugs in different situations.

    ACE inhibitors (enalapril, lisinopril, perindopril, captopril, etc.), in addition to a pronounced hypotensive effect, have organoprotective properties - they reduce the risk of developing complications of atherosclerosis, reduce left ventricular hypertrophy, and slow down the decline in kidney function. Drugs in this group are well tolerated and do not have a negative effect on lipid metabolism and blood glucose levels, which allows their use in cases where arterial hypertension is combined with metabolic syndrome or diabetes mellitus, as well as in patients who have suffered a myocardial infarction, in the case of chronic cardiac failure, arrhythmia, atherosclerosis and renal dysfunction.

    Beta-blockers (atenolol, bisoprolol, metoprolol, carvedilol, nebivolol) reduce the risk of coronary complications in patients with angina pectoris and cardiovascular accidents in patients who have had myocardial infarction, as well as patients with chronic heart failure, and can be used for tachyarrhythmia. The use of beta blockers is undesirable in patients with metabolic syndrome, lipid metabolism disorders and diabetes mellitus.

    Diuretics (hydrochlorothiazide, chlorthalidone, indapamide, spironolactone) are most often used in combination with other antihypertensive drugs, such as ACE inhibitors, to more effectively control blood pressure. Drugs in this group have proven themselves to be effective in refractory hypertension and chronic heart failure. For continuous use, diuretics are prescribed in minimal doses to reduce the risk of side effects.

    Calcium antagonists (nifedipine, amlodipine, verapamil, diltiazem), in addition to hypotensive, have antianginal and organoprotective effects, reduce the risk of stroke, prevent platelet aggregation, slow down atherosclerotic lesions of the carotid arteries and left ventricular hypertrophy. Calcium antagonists are used either alone or in combination with other antihypertensive drugs(most often ACE inhibitors).

    Angiotensin II receptor blockers

    Angiotensin receptor blockers (losartan, candesartan, telmisartan, valsartan) have cardio- and neuroprotective effects, improve blood glucose control, and have a positive effect on the life expectancy of patients with chronic heart failure. All drugs in this group can be used in the treatment of hypertension in patients with impaired renal function, previous myocardial infarction, metabolic syndrome, gout, and diabetes mellitus.

    Hypertensive crisis - what to do?

    Even with constant antihypertensive therapy, blood pressure may periodically suddenly rise to individually high numbers (without signs of target organ damage). This condition is called an uncomplicated hypertensive crisis; most often it occurs after unusual physical activity, emotional stress, consumption of alcoholic beverages or fatty salty foods.

    And although the uncomplicated form of hypertensive crisis is not considered a life-threatening condition, it cannot be left without treatment, because even a small increase in blood pressure (by 10 mm Hg) increases the risk of cardiovascular complications by 30%.2 And the earlier treatment is started, the less likely there are adverse consequences.

    Antihypertensive drugs for uncomplicated hypertensive crisis are often recommended to be taken sublingually, because This method is convenient for the patient and at the same time ensures rapid development of the therapeutic effect. It is undesirable to reduce blood pressure too quickly - in the first 2 hours by no more than 25% of the initial values ​​and to normal levels within 24 hours. To restore blood pressure control, short-acting drugs that provide a rapid hypotensive effect should be used: nifedipine, captopril, moxonidine, clonidine, propranolol. It is better if a doctor selects a drug to quickly reduce blood pressure, since each of them has contraindications.

    Half an hour after taking 1 tablet of an antihypertensive drug, blood pressure levels should be measured and the effectiveness of treatment assessed. If necessary, to restore normal blood pressure levels, after 30–60 minutes you can additionally take 1 more tablet sublingually or orally. If after this the pressure decreases by less than 25%, you should urgently call a doctor.

    Treatment of associated conditions

    Arterial hypertension rarely develops as a separate disease; in most cases it is accompanied by background disorders that aggravate target organ damage and increase the risk of developing cardiovascular complications. Therefore, in addition to antihypertensive drugs, patients with hypertension are often prescribed lipid-lowering therapy, drugs for the prevention of thrombosis and correction of blood glucose levels in patients with metabolic syndrome and diabetes mellitus.

    A particularly important role in arterial hypertension is played by taking statins (simvastatin, atorvastatin, rosuvastatin) - drugs that reduce the level of total cholesterol, low-density lipoproteins and triglycerides. Long-term use of statins makes it possible to stop atherosclerotic vascular damage, suppress the inflammatory process in the plaque, improve endothelial function and thereby significantly reduce the risk of cardiovascular accidents (myocardial infarction and stroke). First of all, statins are prescribed to patients with coronary artery disease, as well as after myocardial infarction.

    Preventive antiplatelet therapy is also prescribed to patients at high cardiovascular risk, people with impaired renal function, and anyone who has undergone vascular surgery (bypass surgery, stenting). Drugs in this group prevent the formation of blood clots and reduce the risk of arterial thrombosis. The most widely used drugs today are acetylsalicylic acid, clopidogrel and dipyridamole, which are prescribed in long courses in minimal therapeutic doses.

    And, of course, all these drugs, like antihypertensive therapy, are prescribed only by the attending physician, because any self-medication for hypertension can be dangerous, which is something that the pharmacy visitor must be reminded of.

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