Treatment of hypertension national guidelines. Arterial hypertension European guidelines

The material was prepared by Villevalde S.V., Kotovskaya Yu.V., Orlova Ya.A.

The highlight of the 28th European Congress on Hypertension and Cardiovascular Prevention was the first presentation of a new version of the European Society of Cardiology and the European Society of Hypertension Joint Guidelines for the Management of Arterial Hypertension (AH). The text of the document will be published on August 25, 2018, simultaneously with the official presentation at the congress of the European Society of Cardiology, which will be held on August 25-29, 2018 in Munich. The publication of the full text of the document will undoubtedly give rise to analysis and detailed comparison with the recommendations of the American societies, presented in November 2017 and radically changing the diagnostic criteria for hypertension and target levels of blood pressure (BP). The purpose of this material is to provide information on the key provisions of the updated European recommendations.

You can watch the full recording of the plenary meeting, where the recommendations were presented, on the website of the European Society for Hypertension www.eshonline.org/esh-annual-meeting.

Classification of blood pressure levels and definition of hypertension

The experts of the European Society for Hypertension retained the classification of blood pressure levels and the definition of hypertension and recommend classifying blood pressure as optimal, normal, high normal, and distinguishing degrees 1, 2 and 3 of hypertension (recommendation class I, level of evidence C) (Table 1).

Table 1 Classification of clinical BP

The criterion for hypertension according to the clinical measurement of blood pressure remained the level of 140 mm Hg. and above for systolic (SBP) and 90 mm Hg. and above - for diastolic (DBP). For home measurement of blood pressure, SBP of 135 mm Hg was retained as a criterion for hypertension. and above and / or DBP 85 mm Hg. and higher. According to the data of 24-hour blood pressure monitoring, the diagnostic cut-off points for the average daily blood pressure were 130 and 80 mm Hg, respectively, daytime - 135 and 85 mm Hg, night - 120 and 70 mm Hg (Table 2) .

Table 2. Diagnostic criteria for hypertension according to clinical and outpatient measurements

BP measurement

The diagnosis of hypertension continues to be based on clinical BP measurements, with the use of ambulatory BP measurements being encouraged and the complementary value of 24-hour monitoring (ABPM) and home BP measurement being emphasized. With regard to office BP measurement without the presence of medical personnel, it is recognized that there are currently insufficient data to recommend it for widespread clinical use.

The advantages of ABPM include: detection of white coat hypertension, stronger predictive value, assessment of BP at night, measurement of BP in the patient's real life, the additional ability to identify predictive BP phenotypes, a wide range of information in a single study, including short-term BP variability. The limitations of ABPM include the high cost and limited availability of the study, as well as its possible inconvenience for the patient.

Advantages of home BP measurement include detection of white-coat hypertension, cost-effectiveness and wide availability, BP measurement in familiar settings where the patient is more relaxed than at the doctor's office, patient participation in BP measurement, reusability over long periods of time, and assessment of variability "day by day". The disadvantage of the method is the possibility of obtaining measurements only at rest, the probability of erroneous measurements and the absence of measurements during sleep.

The recommended indications for ambulatory BP measurement (ABPM or home BP) are: conditions where there is a high likelihood of white-coat hypertension (grade 1 hypertension on clinical measurement, significant increase in clinical BP without target organ damage associated with hypertension), conditions when occult hypertension is highly likely (high clinically measured normal BP, normal clinical BP in a patient with target organ damage or high overall cardiovascular risk), postural and postprandial hypotension in patients not receiving and receiving antihypertensive therapy, evaluation of resistant hypertension , assessment of BP control, especially in high-risk patients, excessive BP response to exercise, significant variability in clinical BP, assessment of symptoms suggestive of hypotension during antihypertensive therapy. A specific indication for ABPM is assessment of nocturnal BP and nocturnal BP reduction (eg, in suspected nocturnal hypertension in patients with sleep apnea, chronic kidney disease (CKD), diabetes mellitus (DM), endocrine hypertension, autonomic dysfunction).

Screening and diagnosis of hypertension

For the diagnosis of hypertension, clinical measurement of blood pressure is recommended as the first step. If hypertension is identified, it is recommended to either measure BP at follow-up visits (except in cases of grade 3 BP elevation, especially in high-risk patients) or perform ambulatory BP measurement (ABPM or BP self-monitoring (SBP)). At each visit, 3 measurements should be performed with an interval of 1-2 minutes, an additional measurement should be performed if the difference between the first two measurements is more than 10 mmHg. For the level of blood pressure of the patient take the average of the last two measurements (IC). Ambulatory BP measurement is recommended in a number of clinical situations such as detection of white coat or occult hypertension, quantification of treatment efficacy, and detection of adverse events (symptomatic hypotension) (IA).

If white-coat hypertension or occult hypertension is identified, lifestyle interventions to reduce cardiovascular risk, as well as regular follow-up with ambulatory blood pressure (IC) measurement, are recommended. In patients with white coat hypertension, medical treatment of hypertension may be considered in the presence of hypertension-related target organ damage or high/very high CV risk (IIbC), but routine BP-lowering drugs are not indicated (IIIC) .

In patients with latent hypertension, pharmacological antihypertensive therapy should be considered to normalize ambulatory BP (IIaC), and in treated patients with uncontrolled ambulatory BP, intensification of antihypertensive therapy should be considered due to the high risk of cardiovascular complications (IIaC).

Regarding the measurement of blood pressure, the question of the optimal method for measuring blood pressure in patients with atrial fibrillation remains unresolved.

Figure 1. Algorithm for screening and diagnosing hypertension.

Classification of hypertension and stratification by the risk of developing cardiovascular complications

The Guidelines retain the SCORE approach to overall cardiovascular risk, recognizing that in patients with hypertension, this risk is significantly increased in the presence of target organ damage associated with hypertension (especially left ventricular hypertrophy, CKD). Among the factors affecting the cardiovascular prognosis in patients with hypertension, added (more precisely, returned) the level of uric acid, added early menopause, psychosocial and economic factors, resting heart rate of 80 bpm or more. Asymptomatic target organ damage associated with hypertension is classified as moderate CKD with glomerular filtration rate (GFR)<60 мл/мин/1,73м 2 , и тяжелая ХБП с СКФ <30 мл/мин/1,73 м 2 (расчет по формуле CKD-EPI), а также выраженная ретинопатия с геморрагиями или экссудатами, отеком соска зрительного нерва. Бессимптомное поражение почек также определяется по наличию микроальбуминурии или повышенному отношению альбумин/креатинин в моче.

The list of established diseases of the cardiovascular system is supplemented by the presence of atherosclerotic plaques in imaging studies and atrial fibrillation.

An approach was introduced to classify hypertension by disease stages (hypertension), taking into account the level of blood pressure, the presence of risk factors affecting the prognosis, target organ damage associated with hypertension, and comorbid conditions (Table 3).

The classification covers the range of blood pressure from high normal to grade 3 hypertension.

There are 3 stages of AH (hypertension). The stage of hypertension does not depend on the level of blood pressure, it is determined by the presence and severity of target organ damage.

Stage 1 (uncomplicated) - there may be other risk factors, but there is no target organ damage. At this stage, patients with grade 3 hypertension, regardless of the number of risk factors, as well as patients with grade 2 hypertension with 3 or more risk factors, are classified as high-risk at this stage. The category of moderate-high risk includes patients with grade 2 hypertension and 1-2 risk factors, as well as grade 1 hypertension with 3 or more risk factors. The category of moderate risk includes patients with grade 1 hypertension and 1-2 risk factors, grade 2 hypertension without risk factors. Patients with high normal BP and 3 or more risk factors are at low-moderate risk. The rest of the patients were classified as low risk.

Stage 2 (asymptomatic) implies the presence of asymptomatic target organ damage associated with hypertension; CKD stage 3; Diabetes without target organ damage and implies the absence of symptomatic cardiovascular disease. The state of target organs corresponding to stage 2, with high normal blood pressure, classifies the patient as a moderate-high risk group, with an increase in blood pressure of 1-2 degrees - as a high-risk category, 3 degrees - as a high-very high risk category.

Stage 3 (complicated) is determined by the presence of symptomatic cardiovascular diseases, CKD stage 4 and above, diabetes with target organ damage. This stage, regardless of the level of blood pressure, puts the patient in the category of very high risk.

Assessment of organ lesions is recommended not only to determine the risk, but also for monitoring during treatment. A change in electrocardiographic and echocardiographic signs of left ventricular hypertrophy, GFR during treatment has a high prognostic value; moderate - dynamics of albuminuria and ankle-brachial index. The change in the thickness of the intima-medial layer of the carotid arteries has no prognostic value. There is not enough data to conclude on the prognostic value of the pulse wave velocity dynamics. There are no data on the significance of the dynamics of signs of left ventricular hypertrophy according to magnetic resonance imaging.

The role of statins is emphasized in reducing CV risk, including greater risk reduction while achieving BP control. Antiplatelet therapy is indicated for secondary prevention and is not recommended for primary prevention in patients without cardiovascular disease.

Table 3. Classification of hypertension by stages of the disease, taking into account the level of blood pressure, the presence of risk factors affecting the prognosis, damage to target organs, associated with hypertension and comorbid conditions

Stage of hypertension	Other risk factors, POM and diseases	High normal BP	AG 1 degree	AG 2 degrees	AG 3 degrees
Stage 1 (uncomplicated)	No other FRs	low risk	low risk	moderate risk	high risk
		low risk	moderate risk	Moderate - high risk	high risk
	3 or more RF	Low to moderate risk	Moderate - high risk	high risk	high risk
Stage 2 (asymptomatic)	AH-POM, CKD stage 3 or DM without POM	Moderate - high risk	high risk	high risk	High - very high risk
Stage 3 (complicated)	Symptomatic CVD, CKD ≥ stage 4, or	Very high risk	Very high risk	Very high risk	Very high risk

POM - target organ damage, AH-POM - target organ damage associated with hypertension, RF - risk factors, CVD - cardiovascular disease, DM - diabetes mellitus, CKD - chronic kidney disease

Initiation of antihypertensive therapy

All patients with hypertension or high normal BP are recommended to make lifestyle changes. The timing of initiation of drug therapy (simultaneous with non-drug interventions or delayed) is determined by the level of clinical BP, the level of cardiovascular risk, the presence of target organ damage or cardiovascular disease (Fig. 2). As before, the immediate initiation of drug antihypertensive therapy is recommended for all patients with grade 2 and 3 hypertension, regardless of the level of cardiovascular risk (IA), while the target level of blood pressure should be achieved no later than 3 months.

In patients with grade 1 hypertension, recommendations for lifestyle changes should begin with evaluation of their effectiveness in normalizing blood pressure (IIB). In patients with grade 1 hypertension at high/very high CV risk, with CV disease, kidney disease, or evidence of end organ damage, antihypertensive drug therapy is recommended concomitantly with initiation of lifestyle interventions (IA). A more decisive (IA) than the 2013 Guidelines (IIaB) is the approach to initiating antihypertensive drug therapy in patients with grade 1 hypertension at low-moderate CV risk without heart or kidney disease, without evidence of target organ damage and not normalized BP at 3-6 months of initial lifestyle change strategy.

New in the 2018 Guidelines is the possibility of drug therapy in patients with high normal blood pressure (130-139/85-89 mm Hg) in the presence of a very high cardiovascular risk due to the presence of cardiovascular diseases, especially coronary heart disease (CHD). ) (IIbA). According to the 2013 Guidelines, antihypertensive drug therapy was not indicated in patients with high normal BP (IIIA).

One of the new conceptual approaches in the 2018 version of the European guidelines is a less conservative approach to BP control in the elderly. Experts suggest lower cut-off levels of blood pressure for initiation of antihypertensive therapy and lower target blood pressure levels in elderly patients, emphasizing the importance of assessing the biological rather than chronological age of the patient, taking into account senile asthenia, self-care ability, and tolerability of therapy.

In fit older patients (even those >80 years of age), antihypertensive therapy and lifestyle changes are recommended when SBP is ≥160 mmHg. (IA). Upgraded recommendation grade and level of evidence (to IA vs. IIbC in 2013) for antihypertensive drug therapy and lifestyle changes in fit older patients (> 65 yr but not older than 80 yr) with SBP in the 140-159 mm range Hg, subject to good tolerability of treatment. If therapy is well tolerated, drug therapy may also be considered in frail elderly patients (IIbB).

It should be borne in mind that reaching a certain age by a patient (even 80 years or more) is not a reason for not prescribing or canceling antihypertensive therapy (IIIA), provided that it is well tolerated.

Figure 2. Initiation of lifestyle changes and antihypertensive drug therapy at various levels of clinical BP.

Notes: CVD = cardiovascular disease; CAD = coronary artery disease; AH-POM = target organ damage associated with hypertension

Target BP levels

Presenting their attitude to the results of the SPRINT study, which were taken into account in the United States when formulating new criteria for the diagnosis of hypertension and target levels of blood pressure, European experts point out that office measurement of blood pressure without the presence of medical staff has not previously been used in any of the randomized clinical trials, served as an evidence base for making decisions on the treatment of hypertension. When measuring blood pressure without the presence of medical staff, there is no white coat effect, and compared to the usual measurement, the level of SBP can be lower by 5-15 mmHg. It is hypothesized that SBP levels in the SPRINT study may correspond to SBP levels normally measured at 130-140 and 140-150 mmHg. in groups of more and less intensive antihypertensive therapy.

Experts acknowledge that there is strong evidence of benefit from lowering SBP below 140 and even 130 mmHg. Data from a large meta-analysis of randomized clinical trials (Ettehad D, et al. Lancet. 2016;387(10022):957-967), which showed a significant reduction in the risk of developing major hypertension-associated cardiovascular complications with a decrease in SBP for every 10 mm, are presented. Hg at an initial level of 130-139 mm Hg. (i.e., when SBP levels are less than 130 mm Hg on treatment): the risk of coronary artery disease by 12%, stroke by 27%, heart failure by 25%, major cardiovascular events by 13%, death from any reasons - by 11%. In addition, another meta-analysis of randomized trials (Thomopoulos C, et al, J Hypertens. 2016;34(4):613-22) also demonstrated a reduction in the risk of major cardiovascular outcomes when SBP was less than 130 or DBP was less than 80 mmHg compared with a less intense decrease in blood pressure (mean blood pressure levels were 122.1/72.5 and 135.0/75.6 mm Hg).

However, European experts also provide arguments in support of a conservative approach to target BP levels:

the incremental benefit of lowering BP decreases as BP targets decrease;
achievement of lower blood pressure levels during antihypertensive therapy is associated with a higher incidence of serious adverse events and discontinuation of therapy;
less than 50% of patients on antihypertensive therapy currently achieve target SBP levels<140 мм рт.ст.;
evidence for the benefit of lower BP targets is less strong in several important subpopulations of patients with hypertension: the elderly, those with diabetes, CKD, and coronary artery disease.

As a result, the European recommendations of 2018 designate as the primary goal the achievement of a target level of blood pressure less than 140/90 mmHg. in all patients (IA). Subject to good tolerability of therapy, it is recommended to reduce blood pressure to 130/80 mm Hg. or lower in most patients (IA). As the target level of DBP, a level below 80 mm Hg should be considered. in all patients with hypertension, regardless of the level of risk or comorbid conditions (IIaB).

However, the same BP level cannot be applied to all hypertensive patients. Differences in target levels of SBP are determined by the age of patients and comorbid conditions. Lower SBP targets of 130 mmHg are suggested. or lower for patients with diabetes (subject to careful monitoring of adverse events) and coronary artery disease (Table 4). In patients with a history of stroke, a target SBP of 120 should be considered (<130) мм рт.ст. Пациентам с АГ 65 лет и старше или имеющим ХБП рекомендуется достижение целевого уровня САД 130 (<140) мм рт.ст.

Table 4. Target levels of SBP in selected subpopulations of patients with hypertension

Notes: DM, diabetes mellitus; CAD, coronary heart disease; CKD, chronic kidney disease; TIA, transient ischemic attack; * - careful monitoring of adverse events; **- if transferred.

The summarizing position of the 2018 Recommendations on target ranges for office blood pressure is presented in Table 5. A new provision that is important for real clinical practice is the designation of the level below which blood pressure should not be reduced: for all patients it is 120 and 70 mmHg.

Table 5 Target ranges for clinical BP

Age, years	Target ranges for office SBP, mmHg
Age, years					Stroke/
	Aim up<130 or lower if carried Not less<120	Aim up<130 or lower if carried Not less<120	Aim up<140 до 130 if tolerated	Aim up<130 or lower if carried Not less<120	Aim up<130 or lower if carried Not less<120
	Aim up<140 до 130 if tolerated	Aim up<140 до 130 if tolerated	Aim up<140 до 130 if tolerated	Aim up<140 до 130 if tolerated	Aim up<140 до 130 if tolerated
	Aim up<140 до 130 if tolerated	Aim up<140 до 130 if tolerated	Aim up<140 до 130 if tolerated	Aim up<140 до 130 if tolerated	Aim up<140 до 130 if tolerated
Target range for clinical DBP,

Notes: DM = diabetes mellitus, CAD = coronary heart disease, CKD = chronic kidney disease, TIA = transient ischemic attack.

When discussing ambulatory BP targets (ABPM or BPDS), it should be kept in mind that no randomized clinical trial with hard endpoints has used ABPM or systolic blood pressure as criteria for changing antihypertensive therapy. Data on the target levels of ambulatory blood pressure are obtained only by extrapolation of the results of observational studies. In addition, differences between office and ambulatory BP levels decrease as office BP decreases. Thus, the convergence of 24-hour and office blood pressure is observed at a level of 115-120/70 mm Hg. It can be considered that the target level of office SBP is 130 mm Hg. approximately corresponds to a 24-hour SBP level of 125 mmHg. with ABPM and SBP<130 мм рт.ст. при СКАД.

Along with the optimal target levels of ambulatory blood pressure (ABPM and SBP), questions remain about the target levels of blood pressure in young patients with hypertension and low cardiovascular risk, the target level of DBP.

Lifestyle changes

Treatment for hypertension includes lifestyle changes and drug therapy. Many patients will require drug therapy, but image changes are essential. They can prevent or delay the development of hypertension and reduce cardiovascular risk, delay or eliminate the need for drug therapy in patients with grade 1 hypertension, and enhance the effects of antihypertensive therapy. However, lifestyle changes should never be a reason to delay drug therapy in patients at high cardiovascular risk. The main disadvantage of non-pharmacological interventions is the low adherence of patients to their compliance and its decline over time.

Recommended lifestyle changes with proven BP-lowering effects include salt restriction, no more than moderate alcohol consumption, high fruit and vegetable intake, weight loss and maintenance, and regular exercise. In addition, a strong recommendation to stop smoking is mandatory. Tobacco smoking has an acute pressor effect that can increase ambulatory daytime BP. Smoking cessation, in addition to the effect on blood pressure, is also important for reducing cardiovascular risk and preventing cancer.

In the previous version of the guidelines, the levels of evidence for lifestyle interventions were categorized in terms of effects on BP and other cardiovascular risk factors and hard endpoints (CV outcomes). In the 2018 Guidelines, the experts indicated the pooled level of evidence. The following lifestyle changes are recommended for patients with hypertension:

Limit salt intake to 5 g per day (IA). A tougher stance compared to the 2013 version, where a limit of up to 5-6 g per day was recommended;
Limiting alcohol consumption to 14 units per week for men, up to 7 units per week for women (1 unit - 125 ml of wine or 250 ml of beer) (IA). In the 2013 version, alcohol consumption was calculated in terms of grams of ethanol per day;
Heavy drinking should be avoided (IIIA). New position;
Increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil); consumption of low-fat dairy products; low consumption of red meat (IA). The experts emphasized the need to increase the consumption of olive oil;
Control body weight, avoid obesity (body mass index (BMI) >30 kg/m2 or waist circumference over 102 cm in men and over 88 cm in women), maintain a healthy BMI (20-25 kg/m2) and waist circumference (less than 94 cm in men and less than 80 cm in women) to reduce blood pressure and cardiovascular risk (IA);
Regular aerobic exercise (at least 30 minutes of moderate dynamic physical activity 5 to 7 days per week) (IA);
Smoking cessation, support and assistance measures, referral to smoking cessation programs (IB).

Unresolved questions remain about the optimal level of salt intake to reduce cardiovascular risk and the risk of death, the effects of other non-drug interventions on cardiovascular outcomes.

Drug treatment strategy for hypertension

In the new Recommendations, 5 classes of drugs are retained as basic antihypertensive therapy: ACE inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), beta-blockers (BB), calcium antagonists (CA), diuretics (thiazide and tazido-like (TD), such as chlorthalidone or indapamide) (IA). At the same time, some changes in the position of the BB are indicated. They can be prescribed as antihypertensive drugs in the presence of specific clinical situations, such as heart failure, angina pectoris, previous myocardial infarction, the need for rhythm control, pregnancy or its planning. Bradycardia (heart rate less than 60 beats/min) was included as absolute contraindications to BB, and chronic obstructive pulmonary disease was excluded as a relative contraindication to their use (Table 6).

Table 6. Absolute and relative contraindications to the prescription of the main antihypertensive drugs.

Drug class	Absolute contraindications	Relative contraindications
Diuretics		Pregnancy Hypercalcemia hypokalemia
Beta blockers	Bronchial asthma Atrioventricular blockade 2-3 degrees Bradycardia (HR<60 ударов в минуту)*	Metabolic syndrome Impaired glucose tolerance Athletes and physically active patients
Dihydropyridine AK		Tachyarrhythmias Heart failure (CHF with low LV EF, II-III FC) Initial severe swelling of the lower extremities*
Non-dihydropyridine AKs (verapamil, diltiazem)	Sino-atrial and atrioventricular blockade of high gradations Severe left ventricular dysfunction (LVEF)<40%) Bradycardia (HR<60 ударов в минуту)*
	Pregnancy Angioedema in history Hyperkalemia (potassium >5.5 mmol/l)
	Pregnancy Hyperkalemia (potassium >5.5 mmol/l) 2-sided renal artery stenosis	Women of childbearing age without reliable contraception*

Notes: LV EF - left ventricular ejection fraction, FC - functional class. * - Changes in bold type compared to 2013 recommendations.

The experts placed particular emphasis on starting therapy with 2 drugs for most patients. The main argument for using combination therapy as an initial strategy is the reasonable concern that when prescribing one drug with the prospect of further dose titration or the addition of a second drug at subsequent visits, most patients will remain on insufficiently effective monotherapy for a long period of time.

Monotherapy is considered acceptable as a starting point for low-risk patients with grade 1 hypertension (if SBP<150 мм рт.ст.) и очень пожилых пациентов (старше 80 лет), а также у пациенто со старческой астенией, независимо от хронологического возраста (табл. 7).

One of the most important components of successful BP control is patient adherence to treatment. In this regard, combinations of two or more antihypertensive drugs combined in one tablet are superior to free combinations. In the new 2018 Guidelines, the class and level of evidence for initiation of therapy from a double fixed combination (the “one pill” strategy) has been upgraded to IB.

Recommended combinations remain combinations of RAAS blockers (ACE inhibitors or ARBs) with AKs or TDs, preferably in "one pill" (IA). It is noted that other drugs from the 5 main classes can be used in combinations. If dual therapy fails, a third antihypertensive drug should be prescribed. As a base, the triple combination of RAAS blockers (ACE inhibitors or ARBs), AK with TD (IA) retains its priorities. If the target blood pressure levels are not achieved on triple therapy, the addition of small doses of spironolactone is recommended. If it is intolerant, eplerenone or amiloride or high-dose TD or loop diuretics may be used. Beta or alpha blockers may also be added to therapy.

Table 7. Algorithm for medical treatment of uncomplicated hypertension (can also be used for patients with target organ damage, cerebrovascular disease, diabetes mellitus and peripheral atherosclerosis)

Stages of therapy	Preparations	Notes
	ACE inhibitor or ARB AC or TD	Monotherapy for low-risk patients with SAD<150 мм рт.ст., очень пожилых (>80 years) and patients with senile asthenia
	ACE inhibitor or ARB
Triple combination (preferably in 1 tablet) + spironolactone, if intolerant, another drug	ACE inhibitor or ARB AA + TD + spironolactone (25-50mg once daily) or other diuretic, alpha or beta blocker	This situation is regarded as resistant hypertension and requires referral to a specialized center for additional examination.

The Guidelines present approaches to the management of AH patients with comorbid conditions. When AH is combined with CKD, as in the previous Recommendations, it is indicated that it is mandatory to replace TD with loop diuretics when GFR decreases below 30 ml/min/1.73 m2 (Table 8), as well as the impossibility of prescribing two RAAS blockers (IIIA). The issue of "individualization" of therapy depending on the tolerability of treatment, indicators of kidney function and electrolytes (IIaC) is discussed.

Table 8. Algorithm for drug treatment of hypertension in combination with CKD

Stages of therapy	Preparations	Notes
CKD (GFR<60 мл/мин/1,73 м 2 с наличием или отсутствием протеинурии)
Initial therapy Double combination (preferably in 1 tablet)	ACE inhibitor or ARB AC or TD/TPD (or loop diuretic*)	The appointment of BB may be considered at any stage of therapy in specific clinical situations, such as heart failure, angina pectoris, myocardial infarction, atrial fibrillation, pregnancy or its planning.
Triple combination (preferably in 1 tablet)	ACE inhibitor or ARB (or loop diuretic*)
Triple combination (preferably in 1 tablet) + spironolactone** or other drug	ACE inhibitor or ARB+AK+ TD + spironolactone** (25–50 mg once daily) or other diuretic, alpha or beta blocker
- if eGFR<30 мл/мин/1,73м 2 * - Caution: Spironolactone administration is associated with a high risk of hyperkalemia, especially if eGFR is initially<45 мл/мин/1,73 м 2 , а калий ≥4,5 ммоль/л

The algorithm of drug treatment of hypertension in combination with coronary heart disease (CHD) has more significant features (Table 9). In patients with a history of myocardial infarction, it is recommended to include BB and RAAS blockers (IA) in the composition of therapy; in the presence of angina, preference should be given to BB and / or AC (IA).

Table 9. Algorithm for drug treatment of hypertension in combination with coronary artery disease.

Stages of therapy	Preparations	Notes
Initial therapy Double combination (preferably in 1 tablet)	ACE inhibitor or ARB BB or AK AK + TD or BB	Monotherapy for patients with grade 1 hypertension, the very elderly (>80 years) and "fragile". Consider initiating therapy for SBP ≥130 mmHg.
Triple combination (preferably in 1 tablet)	Triple combination of the above drugs
Triple combination (preferably in 1 tablet) + spironolactone or other drug	Add spironolactone (25–50 mg once daily) or other diuretic, alpha or beta blocker to triple combination	This situation is regarded as resistant hypertension and requires referral to a specialized center for additional examination.

An obvious choice of drugs has been proposed for patients with chronic heart failure (CHF). In patients with CHF and low EF, the use of ACE inhibitors or ARBs and beta-blockers is recommended, as well as, if necessary, diuretics and / or mineralocorticoid receptor (IA) antagonists. If the target blood pressure is not achieved, the possibility of adding dihydropyridine AK (IIbC) is suggested. Because no single drug group has been shown to be superior in patients with preserved EF, all 5 classes of antihypertensive agents (ICs) can be used. In patients with left ventricular hypertrophy, it is recommended to prescribe RAAS blockers in combination with AK and TD (I A).

Long-term follow-up of patients with hypertension

The decrease in blood pressure develops after 1-2 weeks from the start of therapy and continues for the next 2 months. During this period, it is important to schedule the first visit to assess the effectiveness of treatment and monitor the development of side effects of drugs. Subsequent monitoring of blood pressure should be carried out at the 3rd and 6th months of therapy. The dynamics of risk factors and the severity of target organ damage should be assessed after 2 years.

Particular attention is paid to the observation of patients with high normal blood pressure and white-coat hypertension, for whom it was decided not to prescribe drug therapy. They should be reviewed annually to assess BP, changes in risk factors, and lifestyle changes.

At all stages of patient monitoring, adherence to treatment should be assessed as a key reason for poor BP control. To this end, it is proposed to carry out activities at several levels:

Physician level (providing information about the risks associated with hypertension and the benefits of therapy; prescribing optimal therapy, including lifestyle changes and combination drug therapy, combined in one tablet whenever possible; making greater use of the patient's capabilities and receiving feedback from him interaction with pharmacists and nurses).
Patient level (self and remote monitoring of blood pressure, use of reminders and motivational strategies, participation in educational programs, self-correction of therapy in accordance with simple algorithms for patients; social support).
The level of therapy (simplification of therapeutic schemes, the "one pill" strategy, the use of calendar packages).
Health care system level (development of monitoring systems; financial support for interaction with nurses and pharmacists; reimbursement of patients for the cost of fixed combinations; development of a national database of drug prescriptions available to doctors and pharmacists; increasing the availability of drugs).

Expanding the possibilities for using 24-hour blood pressure monitoring and self-monitoring of blood pressure in the diagnosis of hypertension
Introduction of new target BP ranges depending on age and comorbidities.
Reducing conservatism in the management of elderly and senile patients. To select the tactics of managing elderly patients, it is proposed to focus not on chronological, but on biological age, which involves assessing the severity of senile asthenia, the ability to self-care and tolerability of therapy.
Implementation of the “one pill” strategy for the treatment of hypertension. Preference is given to the appointment of fixed combinations of 2, and if necessary, 3 drugs. Starting therapy with 2 drugs in 1 tablet is recommended for most patients.
Simplification of therapeutic algorithms. Combinations of a RAAS blocker (ACE inhibitor or ARB) with AKs and/or TDs should be preferred in most patients. BB should be prescribed only in specific clinical situations.
Increasing attention to the assessment of patient adherence to treatment as the main reason for insufficient control of blood pressure.
Increasing the role of nurses and pharmacists in the education, supervision and support of patients with hypertension as an important part of the overall strategy for BP control.

A recording of the plenary meeting of the 28th European Congress on Hypertension and Cardiovascular Prevention with the presentation of recommendations is available at http://www.eshonline.org/esh-annual-meeting/

Villevalde Svetlana Vadimovna – Doctor of Medical Sciences, Professor, Head of the Department of Cardiology, Federal State Budgetary Institution “N.N. V.A. Almazov" of the Ministry of Health of Russia.

Kotovskaya Yuliya Viktorovna - Doctor of Medical Sciences, Professor, Deputy Director for Research at the Russian Research Clinical Gerontological Center of the Russian National Research Medical University named after I. N.I. Pirogov of the Ministry of Health of Russia

Orlova Yana Arturovna – Doctor of Medical Sciences, Professor of the Department of Multidisciplinary Clinical Training, Faculty of Fundamental Medicine, Lomonosov Moscow State University, Head. Department of Age-Associated Diseases of the Medical Research and Educational Center of Moscow State University named after M.V. Lomonosov.

A. V. Bilchenko

On June 9, within the framework of the Congress of the European Society for the Study of Arterial Hypertension (ESH), a draft of new ESH / ESC Guidelines for the treatment of arterial hypertension (AH) was presented, which will make significant changes in approaches to the treatment of patients with hypertension.

Definition and classification of hypertension

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

However, given the importance of “out-of-office” BP measurement and differences in BP levels in patients with different methods of measurement, the ESH/ESC Recommendation for the Treatment of Hypertension (2018) includes a classification of reference BP levels for classifying hypertension using “home” self-measurement and ambulatory BP monitoring ( AMAD) (Table 1).

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

Diagnostics

To make a diagnosis of hypertension, the doctor is recommended to re-measure blood pressure "in the office" according to the method that has not changed, or to evaluate the "out-of-office" measurement of blood pressure (home self-measurement or AMAD) if it is organizationally and economically feasible. Thus, while in-office measurement is recommended for screening for hypertension, out-of-office BP measurements can be used to make a diagnosis. Out-of-office measurement of blood pressure (home self-measurement and/or AMAD) is recommended in certain clinical situations (Table 2).

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

When conducting screening re-measurement of “office” BP, depending on the result obtained, the ESH/ESC Guidelines for the Treatment of Hypertension (2018) propose a diagnostic algorithm using other methods for measuring BP (Fig. 1).

Unresolved, from the point of view of ESH / ESC experts, remains the question of which method of measuring blood pressure to use in patients with permanent atrial fibrillation. There is also no evidence from large comparative studies that any method of out-of-office BP measurement has an advantage in predicting major CV events compared to in-office BP monitoring during therapy.

Assessment of cardiovascular risk and its reduction

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

New risk factors have been added, such as uric acid levels, early onset of menopause in women, psychosocial and socioeconomic factors, resting heart rate (HR) >80 bpm (Table 3).

Also, the assessment of CV risk in hypertensive patients is influenced by the presence of target organ damage (TOI) and diagnosed CV diseases, DM or kidney disease. No significant changes were made in relation to the detection of POM in patients with hypertension in the ESH / ESC (2018) recommendations.

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

Be aware of the extremely low sensitivity of the ECG method for detecting LVH. Thus, when using the Sokolov–Lyon index, the sensitivity is only 11%. This means a large number of false-negative results in the detection of LVH, if, with a negative ECG result, echocardiography is not performed with the calculation of the myocardial mass index.

A classification of AH stages was proposed, taking into account the level of BP, the presence of POM, concomitant diseases, and total CV risk (Table 4).

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

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

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

Initiation of therapy

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

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

Target BP

Changing blood pressure targets has been actively discussed over the past 5 years and was actually initiated during the preparation of the US Joint Committee Recommendations on the Prevention, Diagnosis and Treatment of High Blood Pressure (JNC 8), which were published in 2014. The experts who prepared the JNC 8 Guidelines concluded that observational studies have shown an increase in cardiovascular risk already at SBP levels ≥115 mmHg. Art., and in randomized trials using antihypertensive drugs, only the benefits of lowering SBP to values \u200b\u200bof ≤150 mm Hg were actually proven. Art. .

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

As a result, the number of major CV events was 25% less in the intensive care group. The results of the SPRINT study became the evidence base for the updated American recommendations published in 2017, which set target levels for reducing SBP<130 мм рт. ст. для всех больных АГ с установленным СС заболеванием или расчетным риском СС событий >10% in the next 10 years.

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

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

In addition, the authors of the ESH/ESC Guidelines for the Treatment of Hypertension (2018) cite a large qualitative meta-analysis showing significant benefit from a 10 mmHg reduction in SBP. Art. with initial SBP 130-139 mm Hg. Art. (Table 5).

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

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

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

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

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

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

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

Achieving BP control in patients remains a challenge. In most cases in Europe, blood pressure is controlled in less than 50% of patients. Given the new target levels of blood pressure, the ineffectiveness of monotherapy in most cases, and the decrease in patient adherence to treatment in proportion to the number of pills taken, the following algorithm for achieving blood pressure control was proposed (Fig. 3).

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

Literature

Williams, Mancia, et al. 2018 ESH/ESC Guidelines for the management of arterial hypertension. European Heart Journal. 2018, press.
Piepoli M. F., HoesA. W., AgewallS., AlbusC., BrotonsC., CatapanoA. L., CooneyM. T., CorraU., CosynsB., DeatonC., GrahamI ., HallM. S., HobbsF. D.R., Lochen M. L., LollgenH., Marques-Vidal P., PerkJ., PrescottE., RedonJ., RichterD. J., SattarN. , SmuldersY., TiberiM., van der WorpH. B., van DisI., VerschurenW. M.M., BinnoS. ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Heart Journal. 2016. Aug 1; 37 (29): 2315-2381.
2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014; 311(5): 507-520.
The SPRINT Research Group. N.Engl. J.Med. 2015; 373:2103-2116.
Whelton P. K., CareyR. M., AronowW. S., CaseyD. E.Jr., Collins K. J., Dennison HimmelfarbC., DePalma S.M., GiddingS., JamersonK. A., JonesD. W., MacLaughlin E.J., MuntnerP., OvbiageleB., SmithS. C.Jr., SpencerC. C., StaffordR. S., TalerS. J., ThomasR. J., Williams K. A.Sr., Williamson J. D., Wright J. T.Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/ NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. hypertension. Jun 2018;
71(6): e13-e115.
EttehadD., EmdinC. A., KiranA., AndersonS. G., CallenderT., EmbersonJ., ChalmersJ., RodgersA., RahimiK.Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016. Mar 5; 387 (10022): 957-967.
ThomopoulosC., ParatiG., ZanchettiA. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels – updated overview and meta-analyses of randomized trials. J.Hypertens. 2016. Apr; 34(4):613-22

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

Development mechanisms

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

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

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

The progression of hypertension usually looks like this:

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

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

Causes of the disease

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

Secondary arterial hypertension can be a symptom of various diseases.

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

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

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

coarctation of the aorta;
vasculitis;
narrowing of the renal artery;
collagenoses.

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

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

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

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

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

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

Definition and classification

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

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

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

In addition, hypertension blood pressure may be normal in people who are chronically treated with antihypertensive drugs. The diagnosis in this case is clear based on the history of the disease.

They speak of prehypertension at pressure levels up to 139/89 mm Hg. Art.

Degrees of arterial hypertension:

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

Such a division is to a certain extent conditional, since the same patient under different conditions has different pressure indicators.

The classification given is based on an average of 2 or more values obtained at each of 2 or more visits after the initial review by the physician. Unusually low readings should also be evaluated in terms of clinical significance, because they can not only worsen the patient's well-being, but also be a sign of serious pathology.

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

Severe arterial hypertension, not amenable to treatment, is often associated precisely with an unrecognized secondary form, for example, with primary hyperaldosteronism. The uncontrolled form is diagnosed when the combination of three different antihypertensive medications, including a diuretic, does not bring the pressure to normal.

Clinical signs

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

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

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

An important part of the fight against hypertension is the timely full-fledged medical examination, which each person can undergo free of charge in their clinic. Health Centers also operate throughout the country, where doctors will talk about the disease and conduct its initial diagnosis.

Hypertensive crisis and its danger

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

neurological: hypertensive encephalopathy, cerebral vascular accidents, cerebral infarction, subarachnoid hemorrhage, intracranial hemorrhage;
cardiovascular: myocardial ischemia / heart attack, acute pulmonary edema, aortic dissection, unstable angina;
others: acute renal failure, retinopathy with visual loss, eclampsia in pregnancy, microangiopathic hemolytic anemia.

A hypertensive crisis requires immediate medical attention.

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

Diagnosis

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

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

Based on a certain clinical picture or if secondary hypertension is suspected, other studies may be carried out - the level of uric acid in the blood, microalbuminuria (protein in the urine).

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

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

Treatment of arterial hypertension as a first step involves the correction of lifestyle.

Lifestyle

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

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

Medical treatment

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

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

Information for patients

Hypertension is a disease for life. It is impossible to get rid of it, with the exception of secondary hypertension. For optimal control of the disease, constant work on oneself and drug treatment is necessary. The patient must attend the "School for Patients with Arterial Hypertension", because adherence to treatment reduces cardiovascular risk and increases life expectancy.

What a patient with hypertension should know and do:

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

Regular monitoring of blood pressure, visits to the doctor and behavioral correction will help a patient with hypertension maintain a high quality of life for many years.

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Features of hypertension grade 3

What is 3 degree hypertension
Risk groups of patients with hypertension
Symptoms
What to look out for
Causes of the development of hypertension of the 3rd degree

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

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

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

What is 3 degree hypertension

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

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

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

Risk groups of patients with hypertension

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

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

Aggravating factors include smoking, lack of physical activity, overweight, chronic stress, poor nutrition, diabetes mellitus, endocrine disorders.

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

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

1 - there are no changes and damages in target organs;
2 - changes in several target organs;
3 - except for target organ damage plus complications: heart attack, stroke.

Symptoms

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

Possible manifestations:

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

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

In response to this, the inner layer is damaged, and the muscular layer of the vessels increases, due to which their lumen narrows. For the same reason, the vessels become less elastic, cholesterol plaques form on their walls, the lumen of the vessels narrows even more, and blood circulation is even more difficult.

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

Heart;
kidneys;
Brain;
Retina.

What's going on in the heart

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

Kidney damage

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

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

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

The situation is aggravated if the patient's vessels are strongly tortuous, which often happens in this part of the body, since the tortuosity contributes to the formation of blood clots. As a result, in hypertension without timely adequate assistance, the brain receives less nutrition and oxygen.

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

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

Impact on the organs of vision

In some patients with grade 3 hypertension with grade 3 risk, retinal vessels are damaged. This negatively affects visual acuity, it decreases, and flickering of “flies” before the eyes is also possible. Sometimes a person feels pressure on the eyeballs, in this state he constantly feels drowsy, his performance decreases.

Another risk is hemorrhage.

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

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

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

There is an opinion that a person immediately feels increased pressure, but this does not always happen. Everyone has their own sensitivity threshold.

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

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

What to look out for

Regular dizziness and headaches;
Feeling of tightness in the temples and heaviness in the head;
Noise in ears;
"Flies" before the eyes;
General decrease in tone4
Sleep disorders.

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

As a result, more serious symptoms appear:

Irritability;
Decreased memory;
Shortness of breath with little physical exertion;
visual disturbances;
Interruptions in the work of the heart.

With grade 3 hypertension, risk 3 is more likely to cause disability due to extensive vascular damage.

Causes of the development of hypertension of the 3rd degree

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

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

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

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

Other diagnostic measures

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

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

The content of glucose in blood plasma;
General analysis of blood and urine;
The level of creatinine, uric acid, potassium;
Determination of creatinine clearance.

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

Treatment of hypertension stage 3 risk 3 involves a set of measures that includes drug therapy, diet and an active lifestyle. It is obligatory to give up bad habits - smoking and drinking alcohol. These factors significantly aggravate the condition of the vessels and increase the risks.

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

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

The main groups of drugs

Diuretic;
ACE inhibitors;
β-blockers;
calcium channel blockers;
AT2 receptor blockers.

In addition to drug therapy, it is necessary to adhere to a diet, work and rest, to give yourself feasible loads. The results of treatment may not be noticeable immediately after it has begun. It takes a long time for the symptoms to start to improve.

Appropriate nutrition in hypertension is an important part of treatment.

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

Salt intake should be kept to a minimum, ideally no more than half a teaspoon per day.

Prohibited Products

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

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

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Hypertensive [hypertensive] heart and kidney disease (I13), Hypertensive [hypertension] kidney disease (I12), Hypertensive heart disease [hypertensive heart disease] (I11), Essential [primary] hypertension ( I10)

Cardiology

general information

Short description

Recommended
Expert Council
RSE on REM "Republican Center for Health Development"
Ministry of Health and Social Development of the Republic of Kazakhstan
dated November 30, 2015
Protocol No. 18

Arterial hypertension- chronic stable increase in blood pressure, in which the level of systolic blood pressure equal to or more than 140 mm Hg. Art., and (or) the level of diastolic blood pressure, equal to or more than 90 mm Hg. in people who are not receiving antihypertensive drugs [Recommendations of the World Health Organization and the International Society on Hypertension 1999].

I. INTRODUCTION

Protocol name: Arterial hypertension.

ICD-10 codes:

I 10 Essential (primary) hypertension;

I 11 Hypertensive heart disease (hypertension with a primary lesion of the heart);

I 12 Hypertensive (hypertonic) disease with a primary lesion of the kidneys;

I 13 Hypertensive (hypertonic) disease with a primary lesion of the heart and kidneys.

Abbreviations used in the protocol: see Appendix 1 of the clinical protocol.

Protocol development date: 2015

Protocol Users: general practitioners, therapists, cardiologists, endocrinologists, nephrologists, ophthalmologists, neuropathologists.

Class I- Reliable evidence and/or consensus among experts that the procedure or treatment is appropriate, useful and effective.

Class II- Conflicting evidence and/or disagreement between experts on the benefits/effectiveness of a procedure or treatment.

Class IIa- prevailing evidence/opinion in support of benefit/effectiveness.

Class IIb- Benefit/efficacy is not well supported by evidence/expert opinions.

Class III Reliable evidence and/or expert consensus that the procedure or treatment is not useful/effective and in some cases may be harmful.

Level of evidence A. Data from multiple randomized clinical trials or meta-analysis.

Level of evidence B. Data from a single randomized trial or non-randomized trials.

Level of evidence C. Only expert consensus, case studies or standard of care.

Classification

Clinical classification

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

Categories of blood pressure	GARDEN		DBP
Optimal	< 120	and	< 80
Normal	120 - 129	and/or	80 - 84
high normal	130-139	and/or	85 - 89
AG 1 degree	140 - 159	and/or	90 - 99
AG 2 degrees	160 - 179	and/or	100 - 109
AG 3 degrees	≥ 180	and/or	≥ 110
Isolated systolic hypertension *	≥ 140	and	< 90

Note: The BP category is defined by the higher level of BP, systolic or diastolic. Isolated systolic hypertension should be classified as grade 1, 2, or 3 according to the level of systolic BP.

Cardiovascular risk is subdivided into different categories based on BP, presence of cardiovascular risk factors, asymptomatic target organ damage, diabetes mellitus, symptomatic cardiovascular disease, and chronic kidney disease (CKD) Table 2.

Table 2- Stratification of total CV risk into categories

Note: Asymptomatic hypertensive patients without CVD, CKD, DM, at a minimum, require total CV risk stratification using the SCORE model.

The factors on the basis of which risk stratification is carried out are presented in Table 3.

Table 3- Factors affecting the prognosis of cardiovascular risk

Risk factors

Male gender.

Age (≥ 55 years - men, ≥ 65 years - women).

Smoking.

Dyslipidemia:

- Total cholesterol > 4.9 mmol/L (190 mg/dL) and/or;

- LDL cholesterol >3.0 mmol/L (115 mg/dL), and/or;

- High-density lipoprotein cholesterol: in men<1.0 ммоль/л (40 мг/дЛ), у женщин < 1.2 ммоль/л (46 мг/дЛ), и/или;

- Triglycerides >1.7 mmol/L (150 mg/dL);

Impaired glucose tolerance

Obesity (BMI≥30 kg/m² (height²)).

Abdominal obesity (waist circumference in men ≥ 102 cm, in women ≥ 88 cm).

Family history of early cardiovascular disease (in men<55 лет; у женщин <65 лет).

Pulse pressure (in elderly and senile people) ≥60 mm Hg.

Electrocardiographic signs of LVH (Sokolov-Lyon index

>3.5 mV, RaVL >1.1 mV; Cornell index >244 mV x ms).

Echocardiographic signs of LVH [LVH index: >115 g/m² in men, >95 g/m² in women (PPT)*.

Hemorrhages or exudates, papilledema

Carotid wall thickening (intima-media thickness >0.9 mm) or plaque

Velocity of the carotid-femoral pulse wave >10 m/sec.

Ankle-brachial index<0,9.

Diabetes

Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) on two consecutive measurements and/or;

HbA1c >7% (53 mmol/mol) and/or;

Post-exercise plasma glucose >11.0 mmol/L (198 mg/dL).

Cerebrovascular disease: ischemic stroke, cerebral hemorrhage, transient ischemic attack.

IHD: myocardial infarction, angina pectoris, coronary revascularization by PCI or CABG.

Heart failure, including heart failure with preserved ejection fraction.

Clinically manifest lesion of peripheral arteries.

CKD with eGFR<30 мл/мин/1,73м² (ППТ); протеинурия (>300 mg per day).

Severe retinopathy: hemorrhages or exudates, swelling of the optic nipple.

Note: * - the risk is maximal in concentric LVH: an increase in the LVH index with a ratio of wall thickness to radius equal to 0.42.

In patients with hypertension, without CVD, CKD, and diabetes, risk stratification is performed using the Systematic Coronary Risk Assessment (SCORE) model.

Table 4- Overall cardiovascular risk assessment

Recommendations	class a	level b
In asymptomatic hypertensive patients without CVD, CKD, and diabetes, risk stratification using the SCORE model is the minimum requirement.	I	B
Since there is evidence that target organ damage is a predictor of CV mortality regardless of SCORE, it is reasonable to identify target organ damage, especially in those at intermediate risk.	IIa	B
Decisions on treatment tactics are recommended to be made depending on the baseline level of total cardiovascular risk.	I	B

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Mandatory examinations at the outpatient stage :

one). Blood pressure measurement in the doctor's office or clinic (office) and out of the office (DMAD and ABPM) are presented in Tables 6, 7, 8, 9.

Office BP - blood pressure measured in a medical facility. The level of office blood pressure is in an independent continuous relationship with the incidence of stroke, myocardial infarction, sudden death, heart failure, peripheral arterial disease, end-stage kidney disease in all age and ethnic groups of patients.

Table 6- Rules for office blood pressure measurement

Allow the patient to sit quietly for a few minutes before measuring blood pressure.

Measure blood pressure at least twice, 1-2 minutes apart, while sitting; if the first two values differ significantly, repeat the measurements. If you think it is necessary, calculate the average value of blood pressure.

To improve measurement accuracy in patients with arrhythmias, such as atrial fibrillation, perform repeated BP measurements.

Use a standard cuff 12-13 cm wide and 35 cm long. However, larger and smaller cuffs should be available, respectively, for full (arm circumference > 32 cm) and thin arms.

The cuff should be at the level of the heart regardless of the position of the patient.

When using the auscultatory method, systolic and diastolic blood pressure is recorded in phases I and V (disappearance) of the Korotkoff sounds, respectively.

At the first visit, blood pressure should be measured in both arms to identify any possible difference. In this case, they are guided by a higher value of blood pressure

In the elderly, diabetics, and patients with other conditions that may be accompanied by orthostatic hypotension, it is advisable to measure blood pressure 1 and 3 minutes after standing.

If blood pressure is measured with a conventional sphygmomanometer, measure the heart rate by palpation of the pulse (at least 30 seconds) after re-measuring blood pressure in the sitting position.

Out-of-hospital BP is assessed using 24-hour BP monitoring (ABPM) or home BP measurement (HBP), which is usually measured by the patient himself. Self-measurement of blood pressure requires training under the supervision of a healthcare professional.

Table 7- Determination of arterial hypertension by office and out-of-office blood pressure values

Category	SBP (mmHg)		DBP (mmHg)
Office AD	≥140	and	≥90
Ambulatory blood pressure monitoring (ABPM)
Daytime (waking)	≥ 135	and/or	≥85
Night (sleep)	≥120	and/or	≥70
Daily (average per day)	≥130	and/or	≥80
Home blood pressure (DMAP)	≥135	and/or	≥85

Controlling blood pressure outside of a health care setting has the advantage of provides a large number of blood pressure indicators, which allows you to more reliably assess the existing blood pressure compared to office blood pressure. ABPM and DMAP provide somewhat different information about a patient's BP status and risk and should be considered as complementary. The data obtained by both methods are quite comparable.

Table 8-Clinical indications for out-of-office BP measurement for diagnostic purposes

Clinical indications for ABPM or DMAD

. Suspicion of "white coat hypertension"
- AG 1 st in the office (medical facility)
- High office BP in patients without target organ damage and at low CV risk

. Suspicion of "masked hypertension":

- High normal blood pressure in the office (medical facility)
- Normal office BP in patients with asymptomatic target organ disease and high CV risk
- Identification of the "white coat" effect in patients with hypertension
- Significant fluctuations in office BP during the same or different visits to the doctor
- Vegetative, orthostatic, postprandial, drug hypotension; hypotension during daytime sleep
- Elevated office BP or suspected preeclampsia in pregnancy
- Identification of true and false resistant hypertension

Specific indications for ABPM

Expressed discrepancies between office and out-of-office blood pressure

Assessment of nocturnal BP drop

Suspicion of nocturnal hypertension or absence of nocturnal BP reduction e.g. in patients with sleep apnea, CKD or diabetes

Assessment of BP variability

"White coat hypertension" is a condition in which, on repeated visits to a medical institution, blood pressure is elevated, and outside of it, with SMAD or DMAD, it is normal. But their cardiovascular risk is lower than in patients with persistent hypertension, especially in the absence of diabetes, end-organ damage, cardiovascular disease, or CKD.

"Masked hypertension" is a condition in which blood pressure may be normal in the office and pathologically elevated outside the hospital, but the cardiovascular risk is in the range corresponding to persistent hypertension. These terms are recommended for use in untreated patients.

Table 9- Rules for out-of-office measurement of blood pressure (DMAP and ABPM)

Rules for DMAD

Blood pressure should be measured daily for at least 3-4 days, preferably for 7 days in a row, in the morning and evening.

Measurement of blood pressure is carried out in a quiet room, with the patient in a sitting position, with support on the back and support for the arm, after 5 minutes of being at rest.

Each time, two measurements should be taken with an interval between them of 1-2 minutes.

Immediately after each measurement, the results are recorded in a standard diary.

Home BP is the average of these results, excluding the first day of monitoring.

Rules for ABPM

ABPM is performed using a portable BP monitor that the patient wears (usually not on the dominant arm) for 24-25 hours, so it provides information about BP during daytime activity and at night while sleeping.

At the moment when the portable monitor is put on the patient, the difference between the initial BP values and the BP values measured by the operator should not exceed 5 mm Hg. If this difference is greater, then the ABPM cuff should be removed and put on again.

The patient is advised to go about their usual daily activities, refraining from heavy exertion, and at the moments of inflation of the cuff, stop, stop talking and keep the hand with the cuff at the level of the heart.

In clinical practice, blood pressure measurements are usually taken at intervals of 15 minutes during the day and at intervals of 30 minutes at night.

At least 70% of daytime and nighttime blood pressure measurements must be correctly performed.

2) Laboratory and instrumental examination:

Hemoglobin and / hematocrit;

Urinalysis: urinary sediment microscopy, microalbuminuria, protein (qualitative) dipstick test (I B).

Biochemical analysis:

Determination of glucose in blood plasma;

Determination of total cholesterol, LDL cholesterol, HDL cholesterol, TG in blood serum;

Determination of potassium and sodium in blood serum;

Determination of uric acid in blood serum;

Determination of serum creatinine (with calculation of GFR) (I B).

ECG in 12 standard leads (I C);

Echocardiography (IIaB).

Additional studies at the outpatient level:

Glycated hemoglobin (if fasting plasma glucose >5.6 mmol/L (102 mg/dL) on two different tests or pre-existing diabetes) to confirm or rule out diabetes;

Determination of protein in the urine (quantitative) with a positive result of a qualitative protein in the urine (if the rapid analysis is positive) - to detect CKD;

The concentration of sodium and potassium in the urine and their ratio - to exclude primary or secondary hyperaldosteronism (IB);

SMAD - to confirm hypertension;

24-hour Holter ECG monitoring - to determine the nature of arrhythmias;

Ultrasound of the carotid arteries (intima-media thickness) (IIaB) - to detect atherosclerosis and plaque in the carotid arteries;

Dopplerography of the vessels of the abdominal cavity and peripheral arteries (IIaB) - to detect atherosclerosis;

Pulse wave velocity measurement (IIaB) - to determine aortic stiffness;

Measurement of the ankle-brachial index (IIaB) - to determine the degree of damage to peripheral arteries and atherosclerosis in general;

Fundus examination (IIaB) - to detect hypertensive retinopathy.

The minimum list of examinations that must be carried out upon referral for planned hospitalization: in accordance with the internal regulations of the hospital, taking into account the current order of the authorized body in the field of healthcare.

Basic (mandatory) diagnostic examinations carried out at the hospital level(during hospitalization, diagnostic examinations are performed that are not carried out at the outpatient level).

In-depth search for signs of damage to the brain CT and MRI (IIb C), heart (echocardiography (IIa B), kidneys (urinary sediment microscopy, microalbuminuria, protein determination (qualitative) protein using test strips (I B)) and vessels (vascular dopplerography) abdominal cavity and peripheral arteries, measurement of pulse wave velocity and ankle-brachial index (IIa B) Mandatory in resistant and complicated hypertension.

Additional diagnostic examinations performed at the inpatient level (during hospitalization, diagnostic examinations are performed that are not performed at the outpatient level).

List of basic and additional diagnostic measures at the stage of emergency medical care

Basic (mandatory) diagnostic examinations carried out at the stage of emergency medical care :

Measurement of blood pressure (table 6) and pulse;

ECG in 12 standard leads.

Diagnostic Criteria for Making a Diagnosis

Initial examination of a patient with hypertension should be directed to:

Confirmation of the diagnosis of hypertension;

Identification of the causes of secondary hypertension;

Assessment of cardiovascular risk, target organ damage, and clinically manifest cardiovascular or renal disease.

This requires: measurement of blood pressure, history taking, including family history, physical examination, laboratory tests, and additional diagnostic tests.

Complaints and anamnesis(table 10)

Check for complaints:

A) headache, dizziness, blurred vision, sensory or motor disorders;

B) chest pain, shortness of breath, fainting, palpitations, arrhythmias, swelling of the ankles;

C) thirst, polyuria, nocturia, hematuria;

D) cold extremities, intermittent lameness;

D) snoring.

When collecting a medical history, you should establish:

Time of first diagnosis of hypertension;

BP values in the past and present;

Assess previous antihypertensive therapy.

Table 10- Collection of individual and family medical history

1. Duration and previous values of elevated blood pressure, including home

2. Risk factors

a) Family and personal history of hypertension and cardiovascular disease.

b) Family and personal history of dyslipidemia.

c) Family and personal history of diabetes mellitus (drugs, glycemia, polyuria).

d) smoking.

e) Features of nutrition.

f) Dynamics of body weight, obesity.

g) Level of physical activity.

h) Snoring, sleep apnea (collection of information also from a partner).

i) Low birth weight.

3. Secondary hypertension

a) Family history of CKD (polycystic kidney disease).

b) A history of kidney disease, urinary tract infections, hematuria, abuse of painkillers (parenchymal kidney disease).

c) Taking medications such as oral contraceptives, licorice, carbenoxolones, vasoconstrictor nasal drops, cocaine, amphetamines, gluco- and mineralocorticoids, non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine.

d) Repeated episodes of sweating, headache, anxiety, palpitations (pheochromocytoma).

e) Periodic muscle weakness and convulsions (hyperaldosteronism);

f) Symptoms suggestive of thyroid disease.

4. Treatment of hypertension

a) Current antihypertensive therapy.

b) Prior antihypertensive therapy.

c) Data on adherence or lack of adherence to

treatment.

d) Efficacy and side effects of drugs.

Physical examination(Table 11) .
During physical examination, the diagnosis of hypertension should be established or confirmed (Table 6), CV risk, signs of secondary hypertension and organ damage should be determined. Palpation of the pulse and auscultation of the heart may reveal arrhythmias. All patients should have their resting heart rate measured. Tachycardia indicates an increased risk of heart disease. An irregular pulse may indicate atrial fibrillation (including asymptomatic). An additional examination to look for vascular lesions is indicated if, when measuring blood pressure in both arms, a difference in SBP > 20 mm Hg is detected. and DBP >10 mmHg

Table 11- Physical examination data indicating organ pathology and secondary nature of hypertension

Signs of target organ damage

. Brain: impaired mobility or sensation.

. Retina: changes in the fundus.

. Heart: pulse, localization and characteristics of the apex beat, arrhythmia, gallop rhythm, rales in the lungs, peripheral edema.

. Peripheral arteries: absence, weakening or asymmetry of the pulse, cold extremities, ischemic ulcers on the skin.

. Carotid arteries: systolic murmur.

Signs of visceral obesity:

. Body weight and height.

. The increase in waist circumference in the standing position, measured between the edge of the last rib and the ilium.

. Increase in body mass index [body weight, (kg)/height, (m)²].

Signs of secondary hypertension

. Signs of Itsenko-Cushing's syndrome.

. Skin manifestations of neurofibromatosis (pheochromocytoma).

. Enlargement of the kidneys on palpation (polycystic).

. The presence of noise in the projection of the renal arteries (renovascular hypertension).

. Murmurs in the heart (coarctation and other diseases of the aorta, disease of the arteries of the upper extremities).

. Decrease in pulsation and blood pressure in the femoral artery, compared with the simultaneous measurement of blood pressure in the arm (coarctation and other diseases of the aorta, damage to the arteries of the lower extremities).

. The difference between blood pressure on the right and left hands (coarctation of the aorta, stenosis of the subclavian artery).

Laboratory Criteria
Laboratory and instrumental examinations are aimed at obtaining data on the presence of additional risk factors, damage to target organs and secondary hypertension. Investigations should be carried out in order from the simplest to the most complex. Details of laboratory studies are presented below in table 12.

Table 12-Laboratory criteria for factors influencing the prognosis of cardiovascular risk

Risk factors

Dyslipidemia:

Total cholesterol > 4.9 mmol/L (190 mg/dL) and/or

LDL cholesterol >3.0 mmol/L (115 mg/dL), and/or

High-density lipoprotein cholesterol: in men<1.0 ммоль/л (40 мг/дЛ), у женщин < 1.2 ммоль/л (46 мг/дЛ), и/или

Triglycerides >1.7 mmol/L (150 mg/dL)

Fasting plasma glucose 5.6 - 6.9 mmol / l (102-125 mg / dL).

Impaired glucose tolerance.

Asymptomatic target organ damage

CKD with eGFR 30-60 ml/min/1.73 m² (BSA).

Microalbuminuria (30-300 mg daily) or albumin to creatinine ratio (30-300 mg/g; 3.4-34 mg/mmol) (preferably in morning urine).

Diabetes

Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) on two consecutive measurements and/or

HbA1c >7% (53 mmol/mol) and/or

Post-exercise plasma glucose >11.0 mmol/L (198 mg/dL).

Clinically manifest cardiovascular or renal disease

CKD with eGFR<30 мл/мин/1,73м² (ППТ); протеинурия (>300 mg per day).

Instrumental criteria:

Increased blood pressure values (see table 7);

ECG in 12 standard leads (Sokolov-Lyon index

>3.5 mV, RaVL >1.1 mV; Cornell index >244 mV x ms) (IC);

Echocardiography (LVH index LVH: >115 g/m² in men, >95 g/m² in women) (IIaB);

Carotid ultrasound (intima-media thickness >0.9 mm) or plaque (IIaB);

Pulse wave velocity measurement>10 m/s (IIaB);

Ankle-brachial index measurement<0,9 (IIaB);

Hemorrhages or exudates, papilledema on fundoscopy (IIaB).

Indications for expert advice

A. Neurologist:

1 acute disorders of cerebral circulation

Stroke (ischemic, hemorrhagic);

Transient disorders of cerebral circulation.

2. Chronic forms of vascular pathology of the brain:

Initial manifestations of insufficient blood supply to the brain;

Encephalopathy.

B. Optometrist:

Hemorrhages in the retina;

Swelling of the nipple of the optic nerve;

Retinal disinsertion;

progressive loss of vision.

V. Nephrologist:

Exclusion of symptomatic nephrogenic hypertension, CKD IV-V st.

G. Endocrinologist:

Exclusion of symptomatic endocrine hypertension, diabetes.

Differential Diagnosis

Differential Diagnosis(table 13)

All patients should be screened for secondary forms of hypertension, which includes a clinical history, physical examination, and routine laboratory tests (Table 13).

Table 13- Clinical signs and diagnosis of secondary hypertension

	Clinical indicators			Diagnostics
Common Causes	Anamnesis	Inspection	Laboratory research	First line studies	Additional/confirmatory studies
Kidney parenchyma damage	History of urinary tract infection, obstruction, hematuria, overuse of painkillers, family history of polycystic kidney disease	Abdominal lumps/lumps (polycystic kidney disease)	Proteinuria, erythrocytes, leukocytes in urine, decreased GFR	Ultrasound of the kidneys	Detailed examination of the kidneys
Renal artery stenosis	Fibromuscular dysplasia: hypertension of young age (especially in women) Atherosclerotic stenosis: sudden onset of hypertension, deterioration or difficulty in control, acute pulmonary edema	Noise on auscultation of the renal arteries	Kidney length difference >1.5 cm (renal ultrasound), rapid deterioration of kidney function (spontaneous or in response to renin-angiotensin-aldosterone system blockers)	2D dopplerography of the kidneys	MRI, spiral CT, intra-arterial digital angiography
Primary aldosteronism	Family history of muscle weakness, hypertension at an early age, or CV complications before age 40	Arrhythmias (with severe hypokalemia)	Hypokalemia (spontaneous or diuretic-induced), incidental finding of adrenal tumor	Aldosterone/renin ratio under standardized conditions (with correction of hypokalemia and discontinuation of drugs that affect the RAAS	Sodium loading, saline infusion, flurocortisone suppression, or captopril test; CT scan of the adrenal glands; adrenal vein biopsy
Pheochromocytoma	Paroxysms of increased blood pressure or crises with existing hypertension; headache, sweating, palpitations, pallor, family history of pheochromocytoma	Skin manifestations of neurofibromatosis (cafe-au-lait spots, neurofibromas)	Incidental finding of tumors of the adrenal glands (or outside the adrenal glands)	Measurement of conjugated urinary metanephrines or free plasma metanephrines	CT or MRI of the abdomen and pelvis; meta-123 I-benzylguanidine scintigraphy; genetic testing for mutations
Cushing's syndrome	Rapid weight gain, polyuria, polydipsia, psychological disorders	Typical appearance (central obesity, moon face, striae, hirsutism)	hyperglycemia	Daily excretion of cortisol in the urine	Dexamethasone test

Treatment abroad

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Treatment

Treatment goals:

Maximum reduction in the risk of developing SSO and death;

Correction of all modifiable risk factors (smoking, dyslipidemia, hyperglycemia, obesity);

Prevention, slowing down the rate of progression and / or reducing POM;

Treatment of clinically manifest and concomitant diseases - IHD, CHF, DM, etc.;

Achievement of target blood pressure levels<140/90 мм.рт.ст. (IA);

Achievement of target blood pressure levels in patients with diabetes<140/85 мм.рт.ст. (IA).

Treatment tactics:

Lifestyle modification: salt restriction, alcohol restriction, weight loss, regular physical activity, smoking cessation (Table 14).

Recommendations	class a	Level b,d	Level b,e
It is recommended to limit salt intake to 5-6 g/day	I	BUT	B
It is recommended to limit alcohol consumption to no more than 20-30 g (ethanol) per day for men and no more than 10-20 g per day for women.	I	BUT	B
It is recommended to increase the intake of vegetables, fruits, low-fat dairy products.	I	BUT	B
In the absence of contraindications, it is recommended to reduce body weight to a BMI of 25 kg/m² and waist circumference to<102 см у мужчин и <88 см у женщин.	I	BUT	B
Regular physical activity is recommended, for example, at least 30 minutes of moderate dynamic physical activity for 5-7 days a week.	I	BUT	B
It is recommended that all smokers be given advice on quitting and offer appropriate assistance.	I	BUT	B

A Recommendation class
b Level of evidence
c References supporting levels of evidence

d based on effect on BP and CV risk
e Based on outcome studies

Medical treatment(Tables 15-16, Figure 1-2, Appendix 2 of the clinical protocol).

All major groups of drugs - diuretics (thiazides, chlorthalidone and indapamide), beta-blockers, calcium antagonists, ACE inhibitors and angiotensin receptor blockers are suitable and recommended for initial and maintenance antihypertensive therapy, either as monotherapy or in certain combinations with each other (IA).

Some drugs may be considered preferable in specific situations because they have been used in these situations in clinical trials or have been shown to be more effective in specific types of IIaC target organ damage (Table 15).

Table 15- Conditions requiring the choice of individual drugs

states	Preparations
Asymptomatic target organ damage
LVH
Asymptomatic atherosclerosis	Calcium antagonists, ACE inhibitors
microalbuminuria	ACE inhibitor, ARB
Impaired kidney function	ACE inhibitor, ARB
Cardiovascular event
History of stroke	Any drug that effectively lowers blood pressure
History of myocardial infarction	BB, ACE inhibitor, ARB
angina pectoris	BB, calcium antagonists
Heart failure	Diuretics, BBs, ACE inhibitors, ARBs, mineralocorticoid receptor antagonists
aortic aneurysm	BB
Atrial fibrillation (prevention)	Can be an ARB, ACE inhibitor, beta-blocker, or a mineralocorticoid receptor antagonist
Atrial fibrillation (ventricular rhythm control)	BB, calcium antagonists (non-dihydropyridine)
End-stage CKD/Proteinuria	ACE inhibitor, ARB
Peripheral arterial disease	ACE inhibitors, calcium antagonists
Other
ISAG (elderly and senile age)
metabolic syndrome	ACE inhibitors, calcium antagonists, ARBs
Diabetes	ACE inhibitor, ARB
Pregnancy	Methyldopa, BB, calcium antagonists
Negroid race	Diuretics, calcium antagonists

Abbreviations: ACE - angiotensin-converting enzyme, ARB - angiotensin receptor blocker, BP - blood pressure, CKD - chronic kidney disease, ISAH - isolated systolic arterial hypertension, LVH - left ventricular hypertrophy

Monotherapy can effectively lower BP in only a limited number of hypertensive patients (low to moderate CV risk), and most patients require a combination of at least two drugs to achieve BP control.

Picture 1- Approaches to the choice of monotherapy or combination therapy for hypertension.

The most widely used two-component drug combinations are shown in the diagram in Figure 2.

Figure 2- Possible combinations of classes of antihypertensive drugs.

Green continuous lines are preferred combinations. Green outline - useful combinations (with some restrictions). Black dotted line - possible combinations, but little studied. The red line is an unrecommended combination. Although verapamil and diltiazem are sometimes used in combination with beta-blockers for pulse control in patients with atrial fibrillation, only dihydroperidine derivatives should normally be used with beta-blockers.

Table 16- Absolute and relative contraindications to the use of antihypertensive drugs

Preparations	Absolute	Relative (possible)
Diuretics (thiazides)	Gout	metabolic syndrome Pregnancy Hypercalcemia hypokalemia
Beta blockers Calcium antagonists (dihydropyridines)	Asthma Atrioventricular blockade of 2-3 degrees	metabolic syndrome Decreased glucose tolerance Athletes and physically active patients COPD (except beta-blockers with vasodilatory effect) Tachyarrhythmias Heart failure
Calcium antagonists (verapamil, diltiazem)	Atrioventricular block (2-3 degrees or blockade of three bundles) Severe LV failure Heart failure
ACE inhibitors	Pregnancy Angioedema Hyperkalemia Bilateral renal artery stenosis
Angiotensin receptor blockers Mineralocorticoid receptor antagonists	Pregnancy Hyperkalemia Bilateral renal artery stenosis Acute or severe renal failure (eGFR<30 мл/мин) Hyperkalemia	Women capable of childbearing

Medical treatment provided at the inpatient level see above (Table 15-16, Figure 1-2, Appendix 2 of the Clinical Protocol) .

Drug treatment provided at the stage of emergency emergency care

At this stage, short-acting drugs are used, including labetalol (not registered in the Republic of Kazakhstan), sodium nitroprusside (not registered in the Republic of Kazakhstan), nicardipine, nitrates, furosemide for parenteral administration, but in severe patients, the doctor should approach treatment individually. Sharp hypotension and a decrease in perfusion of vital organs, especially the brain, should be avoided.

Other treatments: approaches to treatment for various conditions (tables 17-26) .

Treatment tactics for white-coat hypertension and masked hypertension

In individuals with white-coat hypertension, it is reasonable to limit therapeutic intervention to lifestyle changes only, but such a decision should be followed by close follow-up (IIaC).

In patients with white-coat hypertension with a higher CV risk due to metabolic disorders or asymptomatic target organ damage, medical therapy may be appropriate in addition to lifestyle changes (IIbC).

In masked hypertension, it is advisable to prescribe antihypertensive drug therapy along with lifestyle changes, since it has been repeatedly established that this type of hypertension is characterized by a cardiovascular risk very close to that of office and out-of-office hypertension (IIaC).

The tactics of antihypertensive therapy in elderly and senile patients are presented in Table 17.

Table 17- Tactics of antihypertensive therapy in elderly and senile patients

Recommendations	class a	level b
There is evidence to recommend elderly and senile hypertensive patients with SBP levels ≥160 mmHg. decrease in SBP to the level of 140-150 mm Hg.	I	BUT
In hypertensive patients aged<80 лет, находящихся в удовлетворительном общем состоянии, антигипертензивная терапия может считаться целесообразной при САД ≥140 мм рт.ст., а целевые уровни САД могут быть установлены <140 мм рт.ст., при условии хорошей переносимости терапии.	IIb	C
In patients over 80 years of age with a baseline SBP ≥160 mmHg, a decrease in SBP to the range of 140-150 mmHg is recommended, provided that the patients are in good physical and mental condition.	I	AT
In debilitated elderly and senile patients, it is recommended to leave the decision on antihypertensive therapy at the discretion of the attending physician, subject to monitoring of the clinical effectiveness of treatment.	I	C
When a hypertensive patient on antihypertensive therapy reaches 80 years of age, it is reasonable to continue this therapy if it is well tolerated.	IIa	C
In elderly and senile hypertensive patients, any antihypertensive drug can be used, although diuretics and calcium antagonists are preferred in isolated systolic hypertension.	I	BUT

Young adult patients. In the case of an isolated increase in brachial systolic pressure in young people (with DBP<90 мм рт.ст), центральное АД у них чаще всего в норме и им рекомендуется только модификация образа жизни. Медикаментозная терапия может быть обоснованной и целесообразной, и, особенно при наличии других факторов риска, АД должно быть снижено до<140/90 мм.рт.ст.

Antihypertensive therapy in women. Medical therapy is recommended for severe hypertension (SBP >160 mmHg or DBP >110 mmHg) (IC), Table 18.

Recommendations	class a	level b
Hormone replacement therapy and estrogen receptor modulators are not recommended and should not be used for primary or secondary prevention of cardiovascular disease. If their appointment to a woman of relatively young age in perimenopause is considered to eliminate severe symptoms of menopause, then it is necessary to weigh the benefits and potential risks.	III	BUT
Drug therapy may also be appropriate in pregnant women with a persistent increase in blood pressure to ≥150/95 mmHg, as well as in patients with blood pressure ≥140/90 mmHg. in the presence of gestational hypertension, subclinical target organ damage or symptoms.	IIb	C
In women at high risk of preeclampsia, low-dose aspirin may be appropriate from 12 weeks of gestation until delivery if the risk of gastrointestinal bleeding is low.	IIb	AT
In women of childbearing potential, RAS blockers are not recommended and should be avoided.	III	C
The preferred antihypertensive drugs in pregnancy are methyldopa, labetolol, and nifedipine. In urgent cases (preeclampsia), intravenous labetolol or intravenous infusion of sodium nitroprusside is advisable.	IIa	C

Tactics of management of patients with hypertension in metabolic syndrome(table 19).

Table 19- Antihypertensive therapy in MS

Recommendations	class a	level b
Lifestyle changes, in particular weight loss and physical activity.	I	AT
Drugs that potentially improve insulin sensitivity, such as RAS and AK blockers, are preferred. BB (with the exception of vasodilators) and diuretics (preferably in combination with a potassium-sparing diuretic).	IIa	C
It is recommended to prescribe antihypertensive drugs with extreme caution in patients with metabolic disorders with BP ≥140/90 mmHg, after a certain period of lifestyle changes, maintain BP<140/90 мм.рт.ст.	I	AT
In the metabolic syndrome with high normal blood pressure, antihypertensive drugs are not recommended.	III	BUT

Tactics of managing patients with hypertension in diabetes mellitus(table 20).

Target BP<140/85 мм.рт.ст (IA).

Table 20- Antihypertensive therapy in diabetes mellitus

Recommendations	class a	level b
While the appointment of antihypertensive drug therapy for diabetic patients with SBP ≥160 mm Hg. is mandatory, it is strongly recommended to start pharmacotherapy also at SBP ≥140 mm Hg.	I	BUT
In diabetic patients, all classes of antihypertensive drugs are recommended and can be used. RAS blockers may be preferred, especially in the presence of proteinuria or microalbuminuria.	I	BUT
It is recommended to select drugs individually, taking into account concomitant diseases.	I	C
Coadministration of two RAS blockers is not recommended and should be avoided in diabetic patients.	III	AT

Management of patients with nephropathy(table 21).

Table 21- Antihypertensive therapy for nephropathy

Recommendations	class a	level b
Possible decrease in SBP to<140мм.рт.ст	IIa	AT
In the presence of severe proteinuria, SBP may decrease to<130 мм.рт.ст., при этом необходим контроль изменений СКФ.	IIb	AT
RAS blockers are more effective in reducing albuminuria than other antihypertensive drugs and are indicated in hypertensive patients with microalbuminuria or proteinuria.	I	BUT
Achieving target BP usually requires combination therapy; it is recommended to combine RAS blockers with other antihypertensive drugs.	I	BUT
Although the combination of two RAS blockers is more effective in reducing proteinuria, its use is not recommended.	III	BUT
In CKD, aldosterone antagonists should not be recommended, especially in combination with a RAS blocker, due to the risk of a sharp deterioration in kidney function and hyperkalemia.	III	C

Abbreviations: BP, blood pressure, RAS, renin-angiotensin system, CKD, chronic kidney disease, GFR, glomerular filtration rate, SBP, systolic blood pressure.

Tactics of treatment in cerebrovascular disease(table 22).

Table 22- Antihypertensive therapy in cerebrovascular diseases

Recommendations	class a	level b
In the first week after an acute stroke, antihypertensive intervention is not recommended, regardless of BP, although very high SBP should be managed according to the clinical situation.	III	AT
In hypertensive patients with a history of TIA or stroke, antihypertensive therapy is recommended, even if the initial SBP is in the range of 140-159 mm Hg.	I	AT
For hypertensive patients with a history of TIA or stroke, it is advisable to set the target SBP values at the level<140 мм.рт.ст.	IIa	AT
In elderly hypertensive patients with a history of TIA or stroke, SBP values at which antihypertensive therapy is prescribed, as well as target values, may be somewhat higher.	IIa	AT
For the prevention of stroke, any antihypertensive therapy regimens that provide an effective reduction in blood pressure are recommended.	I	BUT

Abbreviations: BP, blood pressure; SBP, systolic blood pressure; TIA, transient ischemic attack.

Tactics of treatment of hypertensive patients with heart disease.

Target SBP: <140 мм.рт.ст. (IIaB), таблица 23.

Table 23- Antihypertensive therapy for heart disease

Recommendations	class a	level b
Patients with hypertension who have recently suffered a myocardial infarction are recommended beta-blockers. For other manifestations of coronary artery disease, any antihypertensive drugs can be prescribed, but beta-blockers and calcium antagonists that relieve symptoms (for angina pectoris) are preferred.	I	BUT
Diuretics, beta-blockers, ACE inhibitors or ARBs, and mineralocorticoid receptor antagonists are recommended to reduce mortality and the need for hospitalization in patients with heart failure or severe left ventricular dysfunction.	I	BUT
In patients at risk for new or recurrent atrial fibrillation, it is reasonable to prescribe ACE inhibitors and ARBs as antihypertensive agents (as well as beta-blockers and mineralocorticoid receptor antagonists if there is concomitant heart failure).	IIa	C
Antihypertensive drugs are recommended for all patients with LVH.	I	AT
In patients with LVH, it is reasonable to start treatment with one of the drugs that has demonstrated a more pronounced effect on the regression of LVH, i.e., an ACE inhibitor, an ARB, and a calcium antagonist.	IIa	AT

Abbreviations: ACE, angiotensin-converting enzyme, ARBs, angiotensin receptor blockers, LVH, left ventricular hypertrophy, SBP, systolic blood pressure.

Tactics of treatment of hypertensive patients with atherosclerosis, arteriosclerosis and peripheral arterial lesions.
Target SBP: <140/90 мм.рт.ст. (IА), так как у них имеется высокий риск инфаркта миокарда, инсульта, сердечной недостаточности и сердечно-сосудистой смерти (таблица 24).

Table 24- Antihypertensive therapy for atherosclerosis, arteriosclerosis, or peripheral arterial disease

Recommendations	class a	level b
In carotid atherosclerosis, it is advisable to prescribe calcium antagonists and ACE inhibitors, since these drugs slowed the progression of atherosclerosis more effectively than diuretics and beta-blockers.	IIa	AT
It is advisable to prescribe any antihypertensive drugs to patients with hypertension with PWV of more than 10 m/sec, provided that the level of blood pressure is steadily reduced to<140/90 мм.рт.ст.	IIa	AT
With careful monitoring, beta-blockers may be considered for the treatment of hypertension in patients with PAD, as they have not been shown to aggravate PAD symptoms.	IIb	BUT

Abbreviations: ACE, angiotensin-converting enzyme; BP, blood pressure; PPA, peripheral arterial disease; PWV, pulse wave velocity.

Treatment strategy for resistant hypertension(table 25).

Table 25- Antihypertensive therapy for resistant hypertension

Recommendations	class a	level b
It is recommended to check whether the drugs used in the multicomponent regimen have any blood pressure lowering effect and stop them if their effect is absent or minimal.	I	C
In the absence of contraindications, it is reasonable to prescribe mineralocorticoid receptor antagonists, amiloride, and the alpha-blocker doxazosin.	IIa	AT
When drug therapy fails, invasive procedures such as renal denervation and baroreceptor stimulation may be considered.	IIb	C
In view of the lack of data on the long-term efficacy and safety of renal denervation and baroreceptor stimulation, it is recommended that these procedures be performed by an experienced physician, and diagnostics and monitoring should be carried out in specialized centers for hypertension.	I	C
It is recommended to consider the possibility of using invasive techniques only in patients with truly resistant hypertension, with office SBP ≥160 mm Hg. or DBP ≥110 mmHg and an increase in blood pressure, confirmed by ABPM.	I	C

Abbreviations: ABPM, 24-hour ambulatory blood pressure monitoring, BP, blood pressure, DBP, diastolic blood pressure, SBP, systolic blood pressure.

malignant hypertension is an emergency, clinically manifested as a significant increase in blood pressure in combination with ischemic damage to target organs (retina, kidney, heart, or brain). Due to the low incidence of this condition, there are no high-quality controlled studies with new drugs. Modern therapy is based on drugs that can be administered intravenously with dose titration, which allows you to act quickly, but smoothly, to avoid severe hypotension and aggravation of ischemic damage to target organs. Among the most commonly used drugs for intravenous use in severely ill patients are labetalol, sodium nitroprusside, nicardipine, nitrates and furosemide. The choice of drug is at the discretion of the physician. If diuretics cannot cope with the volume overload, ultrafiltration or temporary dialysis can sometimes help.

Hypertensive crises and emergencies. Emergency situations in hypertension include a marked increase in SBP or DBP (>180 mmHg or >120 mmHg, respectively), accompanied by a threat or progression

Target organ damage, such as severe neurological signs, hypertensive encephalopathy, cerebral infarction, intracranial hemorrhage, acute left ventricular failure, acute pulmonary edema, aortic dissection, renal failure, or eclampsia.

An isolated sharp increase in blood pressure without signs of acute damage to target organs (hypertensive crises), which often develops against the background of a break in therapy, a decrease in the dose of drugs, and anxiety, does not belong to emergency situations and must be corrected by resuming or intensifying drug therapy and stopping anxiety.

Surgical intervention .
Renal artery sympathetic plexus catheter ablation, or renal denervation, is the bilateral destruction of the nerve plexuses along the renal artery by radiofrequency ablation with a catheter inserted percutaneously through the femoral artery. The mechanism of this intervention is to disrupt the sympathetic effect on the resistance of the renal vessels, on renin release and sodium reabsorption, and to reduce the increased sympathetic tone in the kidneys and other organs observed in hypertension.

Indication for the procedure is resistant uncontrolled essential hypertension (systolic blood pressure when measured at office and DMAD - more than 160 mm Hg or 150 mm Hg - in patients with diabetes mellitus, confirmed by ABPM≥130/80 mm Hg see table 7), despite the triple therapy carried out by a specialist in hypertension (table 25) and the patient's satisfactory adherence to treatment.

Contraindications to the procedure are renal arteries less than 4 mm in diameter and less than 20 mm in length, manipulations on the renal arteries (angioplasty, stenting) in history, renal artery stenosis more than 50%, renal failure (GFR less than 45 ml / min. / 1.75 m²), vascular events (MI, episode of unstable angina, transient ischemic attack, stroke) less than 6 months. before the procedure, any secondary form of hypertension.

Preventive actions(prevention of complications, primary prevention for PHC level, indicating risk factors):
- home monitoring of blood pressure (DMAD);

Diet with restriction of animal fats, rich in potassium;

Reducing the intake of table salt (NaCI) to 4.5 g / day;

Reducing excess body weight;

Stop smoking and limit alcohol consumption;

Regular dynamic physical activity;

Psychorelaxation;

Compliance with the regime of work and rest;

Group lessons in AG schools;

Compliance with the drug regimen.

Treatment of risk factors associated with hypertension(table 26).

Table 26- Treatment of risk factors associated with hypertension

Recommendations	class a	level b
It is recommended to prescribe statins to hypertensive patients with moderate to high cardiovascular risk; low density lipoprotein cholesterol target<3,0 ммоль/л (115 мг/дл).	I	BUT
In the presence of clinically manifest coronary artery disease, statin administration and a target value of low-density lipoprotein cholesterol are recommended.<1,8 ммоль/л (70 мг/дл).)	I	BUT
Antiplatelet therapy, in particular low-dose aspirin, is recommended in hypertensive patients who have already experienced cardiovascular events.	I	BUT
It is reasonable to prescribe aspirin to hypertensive patients with impaired renal function or high cardiovascular risk, provided that blood pressure is well controlled.	IIa	AT
Aspirin is not recommended for cardiovascular prophylaxis in low- and moderate-risk hypertensive patients in whom the absolute benefits and absolute harms of such therapy are equivalent.	III	BUT
In hypertensive patients with diabetes, the HbA1c target during antidiabetic therapy is<7,0%.	I	AT
In more debilitated elderly patients with a long duration of diabetes, a large number of comorbidities and a high risk, HbA1c targets are reasonable.<7,5-8,0%.	IIa	C

Further tactics of the medical worker :

Achievement and maintenance of target blood pressure levels.

When prescribing antihypertensive therapy, scheduled patient visits to the doctor to assess the tolerability, efficacy and safety of treatment, as well as to monitor the implementation of the recommendations received, are carried out at intervals of 2-4 weeks until the target level of blood pressure is reached (delayed response may gradually develop over the first two months).

After reaching the target level of blood pressure against the background of ongoing therapy, follow-up visits for patients medium to low risk are planned at intervals of 6 months.

For the sick at high and very high risk, and for those with low adherence to treatment intervals between visits should not exceed 3 months.

At all planned visits, it is necessary to monitor the implementation of treatment recommendations by patients. Since the state of the target organs changes slowly, it is not advisable to conduct a control examination of the patient to clarify their condition more than once a year.

For individuals with high normal BP or white-coat hypertension Even if they are not on therapy, they should be followed up regularly (at least once a year) with measurements of office and ambulatory blood pressure, as well as assessment of cardiovascular risk.

For dynamic monitoring, telephone contacts with patients should be used to improve adherence to treatment!

To improve adherence to treatment, it is necessary that there is feedback between the patient and the medical staff (patient self-management). For this purpose, it is necessary to use home monitoring of blood pressure (sms, e-mail, social networks or automated methods of telecommunications), aimed at encouraging self-control of the effectiveness of treatment, adherence to doctor's prescriptions.

Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol.

Table 27-Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol