III. Criteria for risk stratification in patients with hypertension. Classification of hypertension: stages, degrees and risk factors Assessment of the risk of arterial hypertension

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2007 (Order No. 764)

Essential [primary] hypertension (I10)

general information

Short description

arterial hypertension- stable increase in systolic blood pressure of 140 mm Hg. and more and / or diastolic blood pressure of 90 mm Hg or more as a result of at least three measurements taken at different times in a calm environment. In this case, the patient should not take drugs, both increasing and lowering blood pressure (1).

Protocol code: P-T-001 "Hypertension"

Profile: therapeutic

Stage: PHC

Code (codes) according to ICD-10: I10 Essential (primary) hypertension

Classification

WHO/IOAG 1999

1. Optimal blood pressure< 120 / 80 мм рт.ст.

2. Normal blood pressure<130 / 85 мм рт.ст.

3. High normal blood pressure or prehypertension 130 - 139 / 85-89 mm Hg.

AH degrees:

1. Degree 1 - 140-159 / 90-99.

2. Grade 2 - 160-179/100-109.

3. Degree 3 - 180/110.

4. Isolated systolic hypertension - 140/<90.

Factors and risk groups

Criteria for stratification of hypertension

*Additional and "new" risk factors (not included in risk stratification).

1. Low risk group (risk 1). This group includes men and women under the age of 55 years with grade 1 hypertension in the absence of other risk factors, target organ damage and associated cardiovascular diseases. The risk of developing cardiovascular complications in the next 10 years (stroke, heart attack) is less than 15%.

2. Medium risk group (risk 2). This group includes patients with hypertension of 1 or 2 degrees. The main sign of belonging to this group is the presence of 1-2 other risk factors in the absence of target organ damage and associated cardiovascular diseases. The risk of developing cardiovascular complications in the next 10 years (stroke, heart attack) is 15-20%.

3. High risk group (risk 3). This group includes patients with grade 1 or 2 hypertension who have 3 or more other risk factors or target organ damage. This group also includes patients with grade 3 hypertension without other risk factors, without target organ damage, without associated diseases and diabetes mellitus. The risk of developing cardiovascular complications in this group in the next 10 years ranges from 20 to 30%.

4. Very high risk group (risk 4). This group includes patients with any degree of hypertension with associated diseases, as well as patients with grade 3 hypertension with other risk factors and/or target organ damage and/or diabetes mellitus, even in the absence of associated diseases. The risk of developing cardiovascular complications in the next 10 years exceeds 30%.

Risk stratification for assessing the prognosis of patients with hypertension

Diagnostics

Diagnostic criteria

Complaints and anamnesis

In a patient with newly diagnosed hypertension, it is necessary careful history taking, which should include:

- the duration of the existence of hypertension and the levels of increased blood pressure in history, as well as the results of previous treatment with antihypertensive drugs,

A history of hypertensive crises;

- data on the presence of symptoms of coronary artery disease, heart failure, CNS disease, peripheral vascular disease, diabetes mellitus, gout, lipid metabolism disorders, broncho-obstructive diseases, kidney disease, sexual disorders and other pathologies, as well as information on drugs used to treat these diseases , especially those that can increase blood pressure;

- identification of specific symptoms that would give reason to assume a secondary nature of hypertension (young age, tremor, sweating, severe treatment-resistant hypertension, noise over the area of ​​the renal arteries, severe retinopathy, hypercreatininemia, spontaneous hypokalemia);

- in women - gynecological history, the relationship of increased blood pressure with pregnancy, menopause, taking hormonal contraceptives, hormone replacement therapy;

- a thorough assessment of lifestyle, including consumption of fatty foods, salt, alcoholic beverages, quantitative assessment of smoking and physical activity, as well as data on changes in body weight throughout life;

- personal and psychological characteristics, as well as environmental factors that could influence the course and outcome of treatment for hypertension, including marital status, the situation at work and in the family, the level of education;

- family history of hypertension, diabetes mellitus, lipid disorders, coronary heart disease (CHD), stroke or kidney disease.

Physical examination:

1. Confirmation of the presence of hypertension and the establishment of its stability (an increase in blood pressure above 140/90 mm Hg in patients who do not receive regular antihypertensive therapy as a result of at least three measurements in different settings).

2. Exclusion of secondary arterial hypertension.

3. Risk stratification of hypertension (determination of the degree of increase in blood pressure, identification of removable and irremovable risk factors, damage to target organs and associated conditions).

Laboratory research: hemoglobin, red blood cells, fasting blood glucose, total cholesterol, HDL cholesterol, fasting triglycerides, uric acid, creatinine, potassium, sodium, urinalysis.

Instrumental research: echocardiography, ultrasound of the carotid and femoral arteries, ultrasound of the kidneys, Doppler ultrasound of the renal vessels, ultrasound of the adrenal glands, radioisotope renography.

Indications for consultation of specialists: according to indications.

Differential diagnosis: no.

List of main diagnostic measures:

1. Evaluation of history data (familial nature of hypertension, kidney disease, early development of coronary artery disease in close relatives; indication of a stroke, myocardial infarction; hereditary predisposition to diabetes mellitus, lipid metabolism disorders).

2. Assessment of lifestyle (nutrition, salt intake, physical activity), nature of work, marital status, family situation, psychological characteristics of the patient.

3. Examination (height, body weight, body mass index, type and degree of obesity, if any, identification of signs of symptomatic hypertension - endocrine stigmas).

4. Measurement of blood pressure repeatedly under different conditions.

5. ECG in 12 leads.

6. Examination of the fundus.

7. Laboratory examination: hemoglobin, red blood cells, fasting blood glucose, total cholesterol, HDL cholesterol, fasting triglycerides, uric acid, creatinine, potassium, sodium, urinalysis.

8. Due to the high prevalence of hypertension in the population, the disease should be screened as part of routine screening for other conditions.

9. Especially screening for hypertension is indicated in individuals with risk factors: a burdened family history of hypertension, hyperlipidemia, diabetes mellitus, smoking, obesity.

10. In persons without clinical manifestations of hypertension, an annual measurement of blood pressure is necessary. Further frequency of blood pressure measurement is determined by the baseline.

List of additional diagnostic measures

As additional instrumental and laboratory tests, if necessary, echocardiography, ultrasound of the carotid and femoral arteries, ultrasound of the kidneys, Doppler ultrasound of the renal vessels, ultrasound of the adrenal glands, radioisotope renography, C-reactive protein in the blood by a quantitative method, microalbuminuria with test strips (required for sugar diabetes), quantitative proteinuria, urinalysis according to Nechiporenko and Zimnitsky, Reberg's test.

Treatment

Treatment tactics

Treatment goals:

1. The goal of treatment is to reduce blood pressure to the target level (in young and middle-aged patients - below< 130 / 85, у пожилых пациентов - < 140 / 90, у больных сахарным диабетом - < 130 / 85). Даже незначительное снижение АД при терапии необходимо, если невозможно достигнуть «целевых» значений АД. Терапия при АГ должна быть направлена на снижение как систолического, так и диастолического артериального давления.

2. Prevention of the occurrence of structural and functional changes in target organs or their reverse development.

3. Prevention of the development of cerebrovascular accidents, sudden cardiac death, heart and kidney failure and, as a result, improved long-term prognosis, i.e. survival of patients.

Non-drug treatment

Changing the patient's lifestyle

1. Non-pharmacological treatment should be recommended for all hypertensive patients, including those requiring drug therapy.

2. Non-drug therapy reduces the need for drug therapy and increases the effectiveness of antihypertensive drugs.

6. Patients with overweight (BMI.25.0 kg/m2) should be advised to reduce weight.

7. It is necessary to increase physical activity through regular exercise.

8. Salt intake should be reduced to less than 5-6 g per day or sodium to less than 2.4 g per day.

9. The consumption of fruits and vegetables should be increased, and foods containing saturated fatty acids should be reduced.

Medical treatment:

1. Use medical therapy immediately for patients at "high" and "very high" risk of developing cardiovascular complications.

2. When prescribing drug therapy, consider the indications and contraindications for their use, as well as the cost of drugs.

4. Start therapy with minimal doses of drugs to avoid side effects.

The main antihypertensive drugs

Of the six groups of antihypertensive drugs currently used, the effectiveness of thiazide diuretics and β-blockers has been most proven. Drug therapy should begin with low doses of thiazide diuretics, and in the absence of efficacy or poor tolerability, with β-blockers.

Diuretics

Thiazide diuretics are recommended as first-line drugs for the treatment of hypertension. To avoid side effects, it is necessary to prescribe low doses of thiazide diuretics. The optimal dose of thiazide and thiazide-like diuretics is the minimum effective dose, corresponding to 12.5-25 mg of hydrochloride. Diuretics at very low doses (6.25 mg hydrochloride or 0.625 mg indapamide) increase the effectiveness of other antihypertensive drugs without undesirable metabolic changes.

Hydrochlorobiazide inside at a dose of 12.5-25 mg in the morning for a long time. Indapamide orally 2.5 mg (prolonged form 1.5 mg) once in the morning for a long time.

Indications for the appointment of diuretics:

1. Heart failure.

2. AH in old age.

3. Systolic hypertension.

4. AH in people of the Negroid race.

5. Diabetes.

6. High coronary risk.

Contraindications to the appointment of diuretics: gout.

Possible contraindications to the appointment of diuretics: pregnancy.

Rational combinations:

1. Diuretic + β-blocker (hydrochlorothiazide 12.5-25 mg or indapamide 1.5; 2.5 mg + metoprolol 25-100 mg).

2. Diuretic + ACE inhibitor (hydrochlorothiazide 12.5-25 mg or indapamide 1.5; 2.5 mg + enalapril 5-20 mg or lisinopril 5-20 mg or perindopril 4-8 mg. It is possible to prescribe fixed combination drugs - enalapril 10 mg + hydrochlorothiazide 12.5 and 25 mg, as well as a low-dose fixed combination drug - perindopril 2 mg + indapamide 0.625 mg).

3. Diuretic + AT1 receptor blocker (hydrochlorothiazide 12.5-25 mg or indapamide 1.5; 2.5 mg + eprosartan 600 mg). Eprosartan is prescribed at a dose of 300-600 mg / day. depending on the level of blood pressure.

β-blockers

Indications for the appointment of β-blockers:

1. β-blockers can be used as an alternative to thiazide diuretics or as part of combination therapy in the treatment of elderly patients.

2. AH in combination with exertional angina, myocardial infarction.

3. AG + CH (metoprolol).

4. AH + DM type 2.

5. AH + high coronary risk.

6. AH + tachyarrhythmia.

Oral metoprolol, initial dose 50–100 mg/day, usual maintenance dose 100–200 mg/day. for 1-2 receptions.

Contraindications to the appointment of β-blockers:

2. Bronchial asthma.

3. Obliterating vascular diseases.

4. AV block II-III degree.

Possible contraindications to the appointment of β-blockers:

1. Athletes and physically active patients.

2. Diseases of peripheral vessels.

3. Impaired glucose tolerance.

Rational combinations:

1. BAB + diuretic (metoprolol 50-100 mg + hydrochlorothiazide 12.5-25 mg or indapamide 1.5; 2.5 mg).

2. BAB + AA of the dihydropyridine series (metoprolol 50-100 mg + amlodipine 5-10 mg).

3. BAB + ACE inhibitor (metoprolol 50-100 mg + enalapril 5-20 mg or lisinopril 5-20 mg or perindopril 4-8 mg).

4. BAB + AT1 receptor blocker (metoprolol 50-100 mg + eprosartan 600 mg).

5. BAB + α-adrenergic blocker (metoprolol 50-100 mg + doxazosin 1 mg for hypertension against the background of prostate adenoma).

Calcium channel blockers (calcium antagonists)

Long-acting calcium antagonists of the group of dihydropyridine derivatives can be used as an alternative to thiazide diuretics or as part of combination therapy.
It is necessary to avoid the appointment of short-acting calcium antagonists of the group of dihydropyridine derivatives for long-term control of blood pressure.

Indications for the appointment of calcium antagonists:

1. AH in combination with exertional angina.

2. Systolic hypertension (long-acting dihydropyridines).

3. AH in elderly patients.

4. AH + peripheral vasculopathy.

5. AH + carotid atherosclerosis.

6. AH + pregnancy.

7. AH + SD.

8. AH + high coronary risk.

The calcium antagonist of the dihydropyridine series is amlodipine orally at a dose of 5-10 mg once a day.

Calcium antagonist from the group of phenylalkylamines - verapamil inside 240-480 mg in 2-3 doses, prolonged drugs 240-480 mg in 1-2 doses.

Contraindications to the appointment of calcium antagonists:

1. AV block II-III degree (verapamil and diltiazem).

2. CH (verapamil and diltiazem).

Possible contraindications to the appointment of calcium antagonists: tachyarrhythmias (dihydropyridines).

ACE inhibitors

Indications for the appointment of ACE inhibitors:

1. AH in combination with CH.

2. AH + LV contractile dysfunction.

3. Postponed MI.

5. AH + diabetic nephropathy.

6. AH + non-diabetic nephropathy.

7. Secondary prevention of strokes.

8. AH + High coronary risk.

Enalapril orally, with monotherapy, the initial dose is 5 mg 1 time per day, in combination with diuretics, in the elderly or in case of impaired renal function - 2.5 mg 1 time per day, the usual maintenance dose is 10-20 mg, the highest daily dose is 40 mg.

Lisinopril orally, with monotherapy, the initial dose is 5 mg 1 time per day, the usual maintenance dose is 10-20 mg, the highest daily dose is 40 mg.

Perindopril, with monotherapy, the initial dose is 2-4 mg 1 time per day, the usual maintenance dose is 4-8 mg, the highest daily dose is 8 mg.

Contraindications to the appointment of ACE inhibitors:

1. Pregnancy.

2. Hyperkalemia.

3. Bilateral renal artery stenosis

Angiotensin II receptor antagonists (it is proposed to include in the list of vital drugs a drug from the group of AT1 receptor blockers - eprosartan, as a means of choice for patients intolerant to ACE inhibitors and when hypertension is combined with diabetic nephropathy).
Eprosartan is prescribed at a dose of 300-600 mg / day. depending on the level of blood pressure.

Indications for the appointment of angiotensin II receptor antagonists:

1. AH+ intolerance to ACE inhibitors (cough).

2. Diabetic nephropathy.

3. AH + SD.

4. AG + CH.

5. AH + non-diabetic nephropathy.

6. LV hypertrophy.

Contraindications to the appointment of angiotensin II receptor antagonists:

1. Pregnancy.

2. Hyperkalemia.

3. Bilateral stenosis of the renal arteries.

Imidazoline receptor agonists

Indications for the appointment of imidazoline receptor agonists:

1. AH+ metabolic syndrome.

2. AH + SD.

(It is proposed to include in the list of essential drugs the drug of this group - moxonidine 0.2-0.4 mg / day.).

Possible contraindications to the appointment of imidozoline receptor agonists:

1. AV block II-III degree.

2. AH + severe heart failure.

Antiplatelet therapy

For the primary prevention of serious cardiovascular complications (MI, stroke, vascular death), acetylsalicylic acid is indicated in patients at a dose of 75 mg / day. with the risk of their occurrence - 3% per year or > 10% over 10 years. In particular, candidates are patients over 50 years of age with controlled hypertension, in combination with target organ damage and / or diabetes and / or other risk factors for poor outcome in the absence of bleeding tendency.

Lipid-lowering agents (atorvastatin, simvastatin)

Their use is indicated in people at high risk of MI, death from coronary heart disease, or other atherosclerosis due to the presence of multiple risk factors (including smoking, hypertension, early CAD in the family), when a diet low in animal fats has proven ineffective (lovastatin , pravastatin).

Sources and literature

1. Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
   1. 1. Essential hypertension. Guidelines for clinical care. University of Michigan Health system. 2002 2. VHA/DOD Clinical practice guideline for diagnosis and management of hypertension in the primary care setting. 1999. 3. Prodigy guidance. hypertension. 2003. 4. Management of hypertension in adults in primary care. National institute for clinical excellence. 2004 5. Guidelines and protocols. Detection and diagnosis of hypertension. British Columbia medical association. 2003 6. Michigan quality improvement consortium. Medical management of adults with essential hypertension. 2003 7. Arterial hypertension. Seventh Report of the Joint Commission for the Detection and Treatment of Arterial Hypertension with the support of the National Institute of Heart, Lung and Blood Pathology.2003. 8. European Society for Hypertension European Society of Cardiology 2003. Guidelines for the diagnosis and treatment of hypertension. J.hypertension 2003;21:1011-53 9. Clinical guidelines plus pharmacological guide. I.N. Denisov, Yu.L. Shevchenko.M.2004. 10. The 2003 Canadian Recommendations for the management of hypertension diagnosis. 11. The Seventh Report of the Joint national Committee on prevention, detection, evaluation and treatment of high blood pressure. 2003. 12. Okorokov A.N. Diagnosis of diseases of internal organs, volume 7. 13. Kobalava Zh.D., Kotovskaya Yu.V. Arterial hypertension 2000: key aspects of diagnosis and differential. Diagnostics, prevention. Clinics and treatments. 14. Federal Guidelines for the Use of Medicines (formulary system). Issue 6. Moscow, 2005.

Information

Rysbekov E.R., Research Institute of Cardiology and Internal Diseases of the Ministry of Health of the Republic of Kazakhstan.

Attached files

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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, which radically changed 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 grades 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 were 130 and 80 mm Hg for the average daily blood pressure, 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 BP 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.

Benefits 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 elevation 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. When hypertension is detected, 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 occult 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 determining total 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 influencing the cardiovascular prognosis in patients with hypertension, the level of uric acid was added (more precisely, returned), the level of uric acid was added, early menopause, psychosocial and economic factors were added, heart rate at rest was 80 bpm or more. Asymptomatic target organ damage associated with hypertension was 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 has been introduced to classify hypertension by stages of the disease (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 moderate-high risk category 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

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 (simultaneously 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 signs 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 end-organ damage and not normalizing BP at 3-6 months of initial lifestyle change strategy.

A new provision of the 2018 Guidelines is the possibility of drug therapy in patients with high normal blood pressure (130-139 / 85-89 mmHg) 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 BP cut-off levels for initiation of antihypertensive therapy and lower target BP 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 years but not older than 80 years) with SBP in the range of 140-159 mm 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 commonly 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. (that is, when the SBP level is 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;
• achieving 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.

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

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

When discussing ambulatory blood pressure targets (ABPM or BPDS), it should be kept in mind that no randomized clinical trial with hard endpoints has used ABPM or BPAD as criteria for changing antihypertensive therapy. Data on target levels of ambulatory blood pressure are obtained only from 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 CV 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).

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 bpm) 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.

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 target blood pressure levels are not achieved on triple therapy, low-dose 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)

The Guidelines present approaches to the management of AH patients with comorbid conditions. When combining hypertension 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 m 2 (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

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.

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

A 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 combined drug therapy combined in one pill whenever possible; increasing the 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).
• 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 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.

Recording of the plenary session of the 28th

European Congress on Arterial Hypertension and Cardiovascular

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.

Low risk group (risk 1) . This group includes men and women under 55 years of age with grade 1 hypertension in the absence of other risk factors, target organ damage, and associated cardiovascular disease. The risk of developing cardiovascular complications in the next 10 years (stroke, heart attack) is less than 15%.

Medium risk group (risk 2) . This group includes patients with arterial hypertension of 1 or 2 degrees. The main sign of belonging to this group is the presence of 1-2 other risk factors in the absence of target organ damage and associated (concomitant) diseases. The risk of developing cardiovascular complications (stroke, heart attack) in the next 10 years is 15-20%.

High risk group (risk 3) . This group includes patients with grade 1 or 2 hypertension, 3 or more other risk factors, or end-organ damage or diabetes mellitus. The same group includes patients with arterial hypertension of the 3rd degree without other risk factors, without damage to target organs, without associated diseases and diabetes mellitus. The risk of developing cardiovascular complications in this group in the next 10 years ranges from 20 to 30%.

Very high risk group (risk 4) . This group includes patients with any degree of arterial hypertension who have associated diseases, as well as patients with arterial hypertension of the 3rd degree with the presence of other risk factors and / or damage to target organs and / or diabetes mellitus, even in the absence of associated diseases. The risk of developing cardiovascular complications in the next 10 years exceeds 30%.

In 2001, experts from the All-Russian Scientific Society of Cardiology developed "Recommendations for the Prevention, Diagnosis and Treatment of Arterial Hypertension" (hereinafter referred to as the "Recommendations").

Hypertonic diseaseIstages assumes no changes in target organs.

Hypertonic diseaseIIstages characterized by the presence of one or more changes in target organs.

Hypertonic diseaseIIIstages is set in the presence of one or more associated (accompanying) states.

Clinical picture

Subjective manifestations

The uncomplicated course of primary arterial hypertension may not be accompanied by subjective symptoms, in particular, headaches, for a long time, and the disease is detected only with an accidental measurement of blood pressure or during a routine examination.

However, persistent and purposeful questioning of patients allows us to ascertain the subjective manifestations of primary (essential) arterial hypertension in the vast majority of patients.

The most common complaint is on the headache . The nature of headaches varies. In some patients, the headache manifests itself mainly in the morning, after waking up (many cardiologists and neuropathologists consider this a characteristic feature of the disease), in others, the headache appears during a period of emotional or physical stress during the working day or at the end of the working day. The localization of the headache is also diverse - the neck area (most often), temples, forehead, parietal region, sometimes patients cannot even accurately determine the location of the headache or say that "the whole head hurts." Many patients note a clear dependence of the appearance of headaches on changes in weather conditions. The intensity of headaches ranges from mild, perceived rather as a feeling of heaviness in the head (and this is typical for the vast majority of patients), to very significant in severity. Some patients complain of severe stabbing or squeezing pains in various parts of the head.

Headache is often accompanied dizzy, shaky Iem when walking, the appearance of circles and flickering "flies" before the eyes ami, feeling full or tinnitus . However, it should be noted that intense headache, accompanied by dizziness and other complaints mentioned above, is observed with a significant rise in blood pressure and may be a manifestation of a hypertensive crisis.

It should be emphasized that as arterial hypertension progresses, the intensity of headache and the frequency of dizziness increase. It must also be remembered that sometimes a headache is the only subjective manifestation of arterial hypertension.

Approximately 40-50% of patients with primary hypertension have neurotic disorders . They are manifested by emotional lability (unstable mood), irritability, tearfulness, sometimes depression, fatigue, asthenic and hypochondriacal syndromes, depression and cardiophobia are often observed.

17-20% of patients have pain in the heart . Usually these are pains of moderate intensity, localized mainly in the region of the apex of the heart, most often appearing after emotional stress and not associated with physical stress. Cardialgia can be persistent, prolonged, not relieved by nitrates, but, as a rule, pain in the region of the heart decreases after taking sedatives. The mechanism of the appearance of pain in the region of the heart in arterial hypertension remains unclear. These pains are not a reflection of myocardial ischemia.

However, it should be noted that in patients with arterial hypertension with concomitant coronary heart disease, classic angina attacks can be observed, and often they are provoked by an increase in blood pressure.

About 13-18% of patients complain of heartbeat (usually we are talking about sinus tachycardia, less often - paroxysmal tachycardia), feeling of interruption in the region of the heart (due to extrasystolic arrhythmia).

Characteristic are visual impairment complaints (flickering flies before the eyes, the appearance of circles, spots, a feeling of a veil of fog before the eyes, and in severe cases of the disease - progressive loss of vision). These complaints are due to hypertensive angiopathy of the retina and retinopathy.

With the progression of arterial hypertension and the development of complications, complaints appear due to progressive atherosclerosis of the cerebral and peripheral arteries, cerebrovascular accidents, aggravation of the course of coronary heart disease, kidney damage and the development of chronic renal failure, heart failure (in patients with pronounced myocardial hypertrophy).

Analyzing data history , the following important points should be clarified:

the presence of arterial hypertension, diabetes mellitus, cases of early development of coronary heart disease in the next of kin (these factors are taken into account in the subsequent risk stratification);

the patient's lifestyle (abuse of fats, alcohol, salt; smoking, physical inactivity; the nature of the patient's work; the presence of psycho-emotional stressful situations at work; the situation in the family);

features of the character and psycho-emotional status of the patient;

the presence of anamnestic information suggesting symptomatic arterial hypertension;

dynamics of blood pressure indicators both at home and when visiting a doctor;

effectiveness of antihypertensive therapy;

dynamics of body weight and lipid metabolism (cholesterol, triglycerides, lipoproteins).

Obtaining this anamnestic information makes it possible to more accurately determine the risk group, the likelihood of developing coronary heart disease and cardiovascular complications, and more rationally apply antihypertensive therapy.

Objective examination of patients

Inspection. When examining patients with arterial hypertension, attention should be paid to assessing body weight, calculating the body mass index (Quetelet index), identifying obesity and the nature of the distribution of fat. Once again, attention should be paid to the frequent presence of metabolic syndrome. Cushingoid type of obesity (predominant deposition of fat on the face, in the region of the cervical spine, shoulder girdle, chest, abdomen) with purple-red stripes of skin stretching (striae) immediately allows you to associate the presence of arterial hypertension in a patient with hypercortisolism (Itsenko-Cushing's disease or syndrome). ).

In patients with primary arterial hypertension in its uncomplicated course, usually, in addition to excess body weight (in 30-40% of patients), no other characteristic features are found. With severe hypertrophy of the left ventricle and a violation of its function, circulatory failure may develop, which will manifest itself as acrocyanosis, swelling in the feet and legs, shortness of breath, and in severe heart failure, even ascites.

The radial arteries are easily accessible for palpation, it is necessary to assess not only the pulse rate and its rhythm, but also its value on both radial arteries and the condition of the wall of the radial artery. Arterial hypertension is characterized by a tense, hard-to-compress pulse.

Heart study . Arterial hypertension is characterized by the development of left ventricular hypertrophy. This is manifested by a lifting cardiac impulse, and when the dilatation of the cavity of the left ventricle is added, the left border of the heart increases. When listening to the heart, the accent of the II tone over the aorta is determined, and with the prolonged existence of the disease, the systolic ejection murmur (based on the heart). The appearance of this noise in the II intercostal space on the right is extremely characteristic of aortic atherosclerosis, and is also found during a hypertensive crisis.

With significantly pronounced hypertrophy of the myocardium of the left ventricle, an abnormal IV tone may appear. Its origin is due to the active contraction of the left atrium with high diastolic pressure in the cavity of the left ventricle and impaired relaxation of the ventricular myocardium in diastole. Usually the IV tone is not loud, so it is more often recorded during phonocardiographic examination, less often it is auscultated.

With severe dilatation of the left ventricle and a violation of its contractility, III and IV heart sounds can be heard simultaneously, as well as systolic murmur in the apex of the heart due to mitral regurgitation.

The most important symptom of arterial hypertension is, of course, high blood pressure. The value of systolic blood pressure of 140 mm Hg indicates arterial hypertension. Art. and more and / or diastolic 90 mm Hg. Art. and more.

Currently, many prospective studies have confirmed the position that an increase in both diastolic and systolic blood pressure is a risk factor for the development of cardiovascular complications, such as coronary heart disease (including myocardial infarction), stroke, cardiac and renal insufficiency, and increases mortality from cardiovascular diseases.

The results of the Framingham study convincingly showed that in patients with arterial hypertension, the risk of developing cardiovascular complications over 10 years of follow-up depends on the degree of increase in blood pressure, as well as on the severity of target organ damage, other risk factors and concomitant diseases (associated clinical conditions).

WHO and MOAG experts proposed risk stratification into four categories (low, medium, high and very high) or risk 1, risk 2, risk 3, risk 4, respectively. The risk in each category is calculated from an average of 10 years of data on the probability of death from cardiovascular diseases, as well as myocardial infarction and stroke, according to the results of the Framingham study.

To determine the degree of risk of developing cardiovascular complications, individual for a given patient, it is necessary to assess not only (and not so much) the degree of arterial hypertension, but also the number of risk factors, the involvement of target organs in the pathological process, and the presence of concomitant (associated) cardiovascular diseases.

Etiology and treatment of arterial hypertension

Modern society lives an active life and, accordingly, devotes little time to its own state of health. It is important to monitor the level of blood pressure, since hypotensive and hypertensive disorders from the circulatory system are most common. The pathogenesis of hypertension is quite complicated, but there are certain principles for the treatment of hypertension, the scheme of which is known to many.

It is especially important to monitor blood pressure after the age of 40-45 years. These individuals are at risk for diseases of the cardiovascular system. Arterial hypertension occupies a leading position among the diseases of our time and affects all groups of the population, not bypassing anyone.

Pathogenesis

First of all, it is necessary to analyze the reasons, to establish why high blood pressure occurs. The pathogenesis of arterial hypertension is determined by a change in many factors that affect the functioning of the cardiovascular system.

Postnov's theory defines the causes of the disease as a consequence of impaired ion transport and damage to cell membranes. With all this, cells try to adapt to adverse changes and maintain unique functions. This is due to such factors:

• an increase in the active action of neurohumoral systems;
• change in the hormonal interaction of cells;
• calcium exchange.

The pathogenesis of hypertension largely depends on the calcium load of cells. It is important for the activation of cell growth and the ability of smooth muscles to contract. First of all, calcium overload leads to hypertrophy of blood vessels and the muscular layer of the heart, which increases the rate of development of hypertension.

The pathogenesis of hypertension is closely related to hemodynamic disorders. This deviation occurs as a result of neurohumoral pathologies of the adaptive and integral systems of the human body. Pathologies of the integral system include the following conditions:

• dysfunction of the heart, blood vessels, kidneys;
• increased amount of fluid in the body;
• accumulation of sodium and its salts;
• an increase in the concentration of aldosterone.

Multifactorial hypertension, the pathogenesis of which is rather ambiguous, is also determined by tissue insulin resistance. The development of hypertension depends on the adrenergic sensitivity of vascular receptors and the density of their location, the intensity of the weakening of vasodilator stimuli, the absorption of sodium by the body and the nature of the functioning of the sympathetic nervous system.

If a patient develops arterial hypertension, its pathogenesis depends on the correctness of biological, hormonal and neuroendocrine rhythms that control the functioning of the cardiovascular system. There is a theory that the etiopathogenesis of hypertension depends on the concentration of sex hormones.

Etiology

The etiology and pathogenesis of hypertension are closely related. It was not possible to establish the exact cause of this disease, because hypertension can be both an independent disease and a sign of the development of other pathological processes in the body. There are many theories about the causes, but numerous studies have identified the main etiological factor of hypertension - high nervous tension.

With glomerulonephritis, hypertension is also likely. Its etiology is determined by a violation of the processes of sodium metabolism in the body.

If arterial hypertension develops, its etiology and pathogenesis are usually determined by such conditions:

• tonic contractions of arteries and arterioles;
• decrease in the concentration of prostaglandins;
• increased secretion of pressor hormones;
• dysfunction of the cerebral cortex;
• increased concentration of cadmium;
• lack of magnesium;
• restructuring of the hypothalamic part of the brain due to age;
• excessive salt intake;
• long-term nervous fatigue;
• heredity.

First of all, the etiology of arterial hypertension is closely related to the state of the human central nervous system, so any nervous tension or stress affects the level of blood pressure. In cases where a patient develops hypertension, the etiology can be extremely extensive, so the diagnosis should be directed to establishing the exact cause of the increase in blood pressure.

Stages of the disease

Hypertensive syndrome or hypertension is a disease that progresses and, as it develops, passes from one phase to another. There are such stages of the pathological process:

• the first (the easiest);
• second;
• the third (with the risk of death).

The first stage of the disease is the easiest. The level of blood pressure does not constantly rise in a person, this condition does not cause much harm to the internal organs. Treatment of this form of the disease is carried out without the use of drug therapy, but under the supervision of a specialist.

In the absence of any actions aimed at treating high vascular tone, the disease can go into a more severe form - the second stage. In this case, damage to internal organs that are sensitive to sudden pressure drops is already possible. These include the organs of vision, kidneys, brain and, of course, the heart. A person develops such pathologies:

• pathology of the carotid arteries (thickening of the intima, the development of atherosclerotic plaques);
• microalbuminuria;
• narrowing of the retinal arteries;
• pathology of the left ventricle of the heart.

With a disease of the third degree, all internal organs are seriously damaged, complications are possible, up to death. Against the background of arterial hypertension, the following conditions develop:

• aortic dissection;
• proteinuria;
• hemorrhages in the retina;
• vascular dementia;
• acute hypertensive encephalopathy;
• transient ischemic attack;
• stroke;
• heart failure 2-3 degrees;
• myocardial infarction.

If the diagnosis was not carried out in a timely manner or the research data were interpreted correctly, the chance of a successful outcome for the patient decreases.

Clinical picture

The manifestations of the disease are typical and easily recognizable. In the early stages of hypertension, a person does not notice for a long time that he has any problems with the level of blood pressure. Typical symptoms (clinic of hypertension) appear over time:

• cardialgia (heart pain);
• pressure lability;
• nosebleeds;
• dizziness;
• heaviness in the back of the head;
• pressing headache.

The most common sign of high blood pressure is a headache in the morning, frequent dizziness, heaviness in the back of the head. In the case when the pressure rises above normal, a person has bleeding from the nose, after which the pain subsides or disappears completely.

Very often, an increase in blood pressure can be asymptomatic, obvious manifestations occur only with labile hypertension or a hypertensive crisis. If hypertension develops in parallel with coronary heart disease, then cardialgia is possible. In the third stage of the disease, there is a high risk of heart and kidney failure, hypertensive encephalopathy, sudden cardiac asthma, and arrhythmias.

Treatment

Modern medicine keeps pace with the times and is constantly evolving. Every day, more and more new ways of treating arterial hypertension are being found, but a long-established therapy algorithm exists and is effectively used. All treatment consists of two components - drug therapy and lifestyle changes are recommended.

Any treatment is prescribed according to the results of the diagnosis and is determined by the severity of the disease. However, regardless of the phase, the treatment of arterial hypertension consists of the following aspects:

• small physical training;
• rejection of bad habits;
• body weight control;
• "unsalted" diet.

Drug treatment is prescribed by a doctor and carefully monitored by him, because violations of the rules for taking or overdose of drugs can provoke irreparable complications. Treatment with first-line drugs is considered a priority:

• diuretics;
• beta blockers;
• ACE inhibitors (angiotensin-converting enzyme);
• Ca blockers;
• angiotensin blockers.

Treatment begins with the first degree of the disease. If the therapy has not yielded results for a month, then monocomponent drug treatment is replaced by a combined one, while the therapy regimen combines ACE inhibitors with diuretics and beta-blockers, or angiotensin inhibitors are combined with calcium blockers.

Treatment is agreed with the attending physician and carried out in accordance with all recommendations - this excludes the possibility of complications. Self-medication can cause serious harm to the body and cause irreversible changes in the internal organs. A complete diagnosis of the body should be carried out - its results will help identify contraindications to any of the methods of treatment, because therapy should help, and not exacerbate existing problems.

The word "hypertension" means that the human body had to increase blood pressure for some reason. Depending on which can cause this condition, types of hypertension are distinguished, and each of them is treated in its own way.

Classification of arterial hypertension, taking into account only the cause of the disease:

1. Its cause cannot be identified by examining those organs whose disease requires the body to increase blood pressure. It is because of an unexplained reason that all over the world she is called essential or idiopathic(both terms are translated as "unclear reason"). Domestic medicine calls this type of chronic increase in blood pressure hypertension. Due to the fact that this disease will have to be reckoned with all life (even after the pressure returns to normal, certain rules will need to be followed so that it does not rise again), in popular circles it is called chronic hypertension, and it is she who is divided into degrees, stages and risks discussed below.
2. - one whose cause can be identified. She has her own classification - according to the factor that "activated" the mechanism of increasing blood pressure. We will talk about this a little lower.

Both primary and secondary hypertension are divided according to the type of increase in blood pressure. So, hypertension can be:

There is a classification according to the nature of the course of the disease. It divides both primary and secondary hypertension into:

According to another definition, malignant hypertension is an increase in pressure up to 220/130 mm Hg. Art. and more, when, at the same time, an ophthalmologist detects retinopathy of 3-4 degrees in the fundus (hemorrhages, retinal edema or optic nerve edema and vasoconstriction, and fibrinoid arteriolonecrosis is diagnosed by kidney biopsy).

Symptoms of malignant hypertension are headaches, "flies" before the eyes, pain in the heart, dizziness.

Before that, we wrote “upper”, “lower”, “systolic”, “diastolic” pressure, what does this mean?

Systolic (or “upper”) pressure is the force with which blood presses on the walls of large arterial vessels (that is where it is thrown out) during heart compression (systole). In fact, these arteries, 10-20 mm in diameter and 300 mm or more long, must “compress” the blood that is ejected into them.

Only systolic pressure rises in two cases:

• when the heart ejects a large amount of blood, which is typical for hyperthyroidism - a condition in which the thyroid gland produces an increased amount of hormones that cause the heart to contract strongly and frequently;
• when the elasticity of the aorta is reduced, which is observed in the elderly.

Diastolic (“lower”) is the pressure of the fluid on the walls of large arterial vessels, which occurs during the relaxation of the heart - diastole. In this phase of the cardiac cycle, the following happens: large arteries must transfer the blood that has entered them during systole into the arteries and arterioles of a smaller diameter. After that, the aorta and large arteries need to prevent overloading the heart: while the heart relaxes, taking blood from the veins, the large vessels must have time to relax in anticipation of its contraction.

The level of arterial diastolic pressure depends on:

1. The tone of such arterial vessels (according to Tkachenko B.I. " normal human physiology."- M, 2005), which are called vessels of resistance:
   • mainly those that have a diameter of less than 100 micrometers, arterioles - the last vessels before the capillaries (these are the smallest vessels from where substances penetrate directly into the tissues). They have a muscle layer of circular muscles, which are located between the various capillaries and are a kind of "tap". It depends on the switching of these “faucets” which part of the organ will now receive more blood (that is, nutrition), and which one will receive less;
   • to a small extent, the tone of medium and small arteries (“distribution vessels”), which carry blood to organs and are inside tissues, plays a role;
2. Heart rates: if the heart contracts too often, the vessels do not yet have time to deliver one portion of blood, as they receive the next one;
3. The amount of blood that is included in the circulation;
4. Blood viscosity.

Isolated diastolic hypertension is very rare, mainly in resistance vascular disease.

Most often, both systolic and diastolic pressure increase. It happens like this:

When the heart begins to work against increased pressure, pushing blood into vessels with a thickened muscle wall, its muscle layer also increases (this is a common property for all muscles). This is called hypertrophy, and it mostly affects the left ventricle of the heart because it communicates with the aorta. There is no concept of "left ventricular hypertension" in medicine.

Primary arterial hypertension

The official widespread version says that the causes of primary hypertension cannot be found out. But the physicist Fedorov V.A. and a group of doctors explained the increase in pressure by such factors:

Scrupulously studying the mechanisms of the body, Fedorov V.A. with doctors they saw that the vessels cannot feed every cell of the body - after all, not all cells are close to the capillaries. They realized that cell nutrition is possible thanks to microvibration - a wave-like contraction of muscle cells, which make up more than 60% of body weight. Such, described by academician Arinchin N.I., ensure the movement of substances and the cells themselves in the aqueous medium of the intercellular fluid, making it possible to provide nutrition, remove substances used in the process of life, and carry out immune reactions. When microvibration in one or more areas becomes insufficient, a disease occurs.

In their work, the muscle cells that create microvibration use the electrolytes available in the body (substances that can conduct electrical impulses: sodium, calcium, potassium, some proteins and organic substances). The balance of these electrolytes is maintained by the kidneys, and when the kidneys become ill or the volume of working tissue in them decreases with age, microvibrations begin to be lacking. The body does its best to eliminate this problem by increasing blood pressure so that more blood flows to the kidneys, but the whole body suffers because of this.

Deficiency of microvibration can lead to the accumulation of damaged cells and decay products in the kidneys. If they are not removed from there for a long time, then they are transferred to the connective tissue, that is, the number of working cells decreases. Accordingly, the performance of the kidneys decreases, although their structure does not suffer.

The kidneys themselves do not have their own muscle fibers and receive microvibration from neighboring working muscles of the back and abdomen. Therefore, physical activity is necessary primarily to maintain the tone of the muscles of the back and abdomen, which is why correct posture is necessary even in a sitting position. According to Fedorov V.A., “constant tension of the back muscles with correct posture significantly increases the saturation of internal organs with microvibration: kidneys, liver, spleen, improving their work and increasing the resources of the body. This is a very important circumstance that increases the importance of posture. ("" - Vasiliev A.E., Kovelenov A.Yu., Kovlen D.V., Ryabchuk F.N., Fedorov V.A., 2004)

The way out of the situation can be the message of additional microvibration (optimally - in combination with thermal exposure) to the kidneys: their nutrition is normalized, and they return the electrolyte balance of the blood to the "initial settings". Hypertension is thus resolved. At its initial stage, such treatment is enough to naturally lower blood pressure, without taking additional medications. If a person’s disease has “gone far” (for example, it has a 2-3 degree and a risk of 3-4), then a person may not do without taking medications prescribed by a doctor. At the same time, the message of additional microvibration will help to reduce the doses of medications taken, and therefore, reduce their side effects.

• in 1998 - at the Military Medical Academy. S.M. Kirov, St. Petersburg (“ . »)
• in 1999 - on the basis of the Vladimir Regional Clinical Hospital (" " and " »);
• in 2003 - at the Military Medical Academy. CM. Kirov, St. Petersburg (" . »);
• in 2003 - on the basis of the State Medical Academy. I.I. Mechnikova, St. Petersburg (“ . »)
• in 2009 - in the boarding house for labor veterans No. 29 of the Department of Social Protection of the Population of Moscow, the Clinical Hospital of Moscow No. 83, the clinic of the Federal State Institution FBMC named after. Burnazyan FMBA of Russia ("" Dissertation of the candidate of medical sciences Svizhenko A. A., Moscow, 2009).

Types of secondary arterial hypertension

Secondary arterial hypertension is:

1. (caused by a disease of the nervous system). It is divided into:
   • centrogenous - it occurs due to violations of the work or structure of the brain;
   • reflexogenic (reflex): in a certain situation or with constant irritation of the organs of the peripheral nervous system.
2. (endocrine).
3. - occurring when organs such as the spinal cord or brain suffer from a lack of oxygen.
4. , it also has its division into:
   • renovascular, when the arteries that bring blood to the kidneys narrow;
   • renoparenchymal, associated with damage to the kidney tissue, because of which the body needs to increase pressure.
5. (due to diseases of the blood).
6. (due to a change in the "route" of blood movement).
7. (when it was caused by several reasons).

Let's talk a little more.

The main command to the large vessels, forcing them to contract, increasing blood pressure, or relax, reducing it, comes from the vasomotor center, which is located in the brain. If its work is disturbed, centrogenous hypertension develops. This can happen due to:

1. Neuroses, that is, diseases when the structure of the brain does not suffer, but under the influence of stress, a focus of excitation is formed in the brain. He activates the main structures that “turn on” the increase in pressure;
2. Brain damage: injuries (concussions, bruises), brain tumors, stroke, inflammation of a part of the brain (encephalitis). To increase blood pressure should be:

• or structures that directly affect blood pressure are damaged (the vasomotor center in the medulla oblongata or the nuclei of the hypothalamus associated with it or the reticular formation);
• or extensive brain damage occurs with an increase in intracranial pressure, when in order to ensure the blood supply to this vital organ, the body will need to increase blood pressure.

Reflex hypertension also belongs to neurogenic ones. They can be:

• conditioned reflex, when at first there is a combination of some event with taking a medicine or a drink that increases blood pressure (for example, if a person drinks strong coffee before an important meeting). After many repetitions, the pressure begins to rise only at the very thought of a meeting, without drinking coffee;
• unconditionally reflex, when the pressure rises after the cessation of constant impulses from inflamed or strangulated nerves that go to the brain for a long time (for example, if a tumor that pressed on the sciatic or any other nerve was removed).

Endocrine (hormonal) hypertension

These are such secondary hypertension, the causes of which are diseases of the endocrine system. They are divided into several types.

Adrenal hypertension

In these glands, lying above the kidneys, a large number of hormones are produced that can affect vascular tone, strength or frequency of heart contractions. An increase in pressure can be caused by:

1. Excessive production of adrenaline and norepinephrine, which is typical for a tumor such as pheochromocytoma. Both of these hormones simultaneously increase the strength and frequency of heart contractions, increase vascular tone;
2. A large amount of the hormone aldosterone, which does not release sodium from the body. This element, appearing in the blood in large quantities, "attracts" water from the tissues to itself. Accordingly, the amount of blood increases. This happens with a tumor that produces it - malignant or benign, with non-tumor growth of the tissue that produces aldosterone, as well as with stimulation of the adrenal glands in severe diseases of the heart, kidneys, and liver.
3. Increased production of glucocorticoids (cortisone, cortisol, corticosterone), which increase the number of receptors (that is, special molecules on the cell that act as a “lock” that can be opened with a “key”) to adrenaline and norepinephrine (they will be the necessary “key” for “ castle") in the heart and blood vessels. They also stimulate the liver to produce the hormone angiotensinogen, which plays a key role in the development of hypertension. An increase in the amount of glucocorticoids is called Itsenko-Cushing's syndrome and disease (a disease when the pituitary gland commands the adrenal glands to produce a large amount of hormones, a syndrome when the adrenal glands are affected).

Hyperthyroid hypertension

It is associated with excessive production by the thyroid gland of its hormones - thyroxine and triiodothyronine. This leads to an increase in the heart rate and the amount of blood ejected by the heart in one contraction.

The production of thyroid hormones can increase with such autoimmune diseases as Graves' disease and Hashimoto's thyroiditis, with inflammation of the gland (subacute thyroiditis), and some of its tumors.

Excessive secretion of antidiuretic hormone by the hypothalamus

This hormone is produced in the hypothalamus. Its second name is vasopressin (translated from Latin means “squeezing the vessels”), and it acts in this way: by binding to receptors on the vessels inside the kidney, it causes their narrowing, as a result of which less urine is formed. Accordingly, the volume of fluid in the vessels increases. More blood flows to the heart - it stretches more. This leads to an increase in blood pressure.

Hypertension can also be caused by an increase in the production in the body of active substances that increase vascular tone (these are angiotensins, serotonin, endothelin, cyclic adenosine monophosphate) or a decrease in the amount of active substances that should dilate blood vessels (adenosine, gamma-aminobutyric acid, nitric oxide, some prostaglandins).

The extinction of the function of the gonads is often accompanied by a constant increase in blood pressure. The age of entry into menopause for each woman is different (it depends on genetic characteristics, living conditions and the state of the body), but German doctors have proven that age over 38 is dangerous for the development of arterial hypertension. It is after 38 years that the number of follicles (from which eggs are formed) begins to decrease not by 1-2 every month, but by dozens. A decrease in the number of follicles leads to a decrease in the production of hormones by the ovaries, as a result, vegetative (sweating, paroxysmal sensation of heat in the upper body) and vascular (reddening of the upper half of the body during an attack of heat, increased blood pressure) disorders develop.

Hypoxic hypertension

They develop when there is a violation of blood delivery to the medulla oblongata, where the vasomotor center is located. This is possible with atherosclerosis or thrombosis of the vessels that carry blood to it, as well as with squeezing of the vessels due to edema and hernias.

Renal hypertension

As already mentioned, there are 2 types:

Vasorenal (or renovascular) hypertension

It is caused by a deterioration in the blood supply to the kidneys due to the narrowing of the arteries supplying the kidneys. They suffer from the formation of atherosclerotic plaques in them, an increase in the muscle layer in them due to a hereditary disease - fibromuscular dysplasia, aneurysm or thrombosis of these arteries, aneurysm of the renal veins.

The basis of the disease is the activation of the hormonal system, due to which the vessels spasm (shrink), sodium is retained and fluid in the blood increases, and the sympathetic nervous system is stimulated. The sympathetic nervous system, through its special cells located on the vessels, activates their even greater compression, which leads to an increase in blood pressure.

Renoparenchymal hypertension

It accounts for only 2-5% of cases of hypertension. It occurs due to diseases such as:

• glomerulonephritis;
• kidney damage in diabetes;
• one or more cysts in the kidneys;
• kidney injury;
• kidney tuberculosis;
• kidney tumor.

With any of these diseases, the number of nephrons (the main working units of the kidneys through which blood is filtered) decreases. The body tries to correct the situation by increasing the pressure in the arteries that carry blood to the kidneys (the kidneys are an organ for which blood pressure is very important, at low pressure they stop working).

Medicinal hypertension

The following drugs can cause an increase in pressure:

• vasoconstrictor drops used for the common cold;
• tableted contraceptives;
• antidepressants;
• painkillers;
• preparations based on glucocorticoid hormones.

Hemic hypertension

Due to an increase in blood viscosity (for example, with Wakez disease, when the number of all its cells in the blood increases) or an increase in blood volume, blood pressure may increase.

Hemodynamic hypertension

This is the name of hypertension, which is based on a change in hemodynamics - that is, the movement of blood through the vessels, usually as a result of diseases of large vessels.

The main disease causing hemodynamic hypertension is coarctation of the aorta. This is a congenital narrowing of the aorta in its thoracic (located in the chest cavity) section. As a result, in order to ensure normal blood supply to the vital organs of the chest cavity and the cranial cavity, blood must reach them through rather narrow vessels that are not designed for such a load. If the blood flow is large, and the diameter of the vessels is small, the pressure in them will increase, which happens with coarctation of the aorta in the upper half of the body.

The body needs the lower limbs less than the organs of these cavities, so the blood already reaches them “not under pressure”. Therefore, the legs of such a person are pale, cold, thin (muscles are poorly developed due to insufficient nutrition), and the upper half of the body has an "athletic" appearance.

Alcoholic hypertension

How ethyl alcohol-based drinks cause an increase in blood pressure is still unclear to scientists, but 5-25% of people who constantly drink alcohol increase blood pressure. There are theories suggesting that ethanol may affect:

• through increased activity of the sympathetic nervous system, which is responsible for vasoconstriction, increased heart rate;
• by increasing the production of glucocorticoid hormones;
• due to the fact that muscle cells more actively capture calcium from the blood, and therefore are in a state of constant tension.

Mixed hypertension

When any provoking factors are combined (for example, kidney disease and taking painkillers), they are added (summation).

Certain types of hypertension that are not included in the classification

There is no official concept of "juvenile hypertension". The increase in blood pressure in children and adolescents is mainly secondary. The most common causes of this condition are:

• Congenital malformations of the kidneys.
• Congenital narrowing of the renal arteries.
• Pyelonephritis.
• Glomerulonephritis.
• Cyst or polycystic kidney disease.
• Tuberculosis of the kidneys.
• Kidney injury.
• Coarctation of the aorta.
• Essential hypertension.
• Wilms tumor (nephroblastoma) is an extremely malignant tumor that develops from the tissues of the kidneys.
• Damage to either the pituitary gland or the adrenal glands, resulting in a lot of glucocorticoid hormones in the body (syndrome and Itsenko-Cushing's disease).
• Thrombosis of the arteries or veins of the kidneys
• Narrowing of the diameter (stenosis) of the renal arteries due to a congenital increase in the thickness of the muscular layer of the vessels.
• Congenital disorder of the adrenal cortex, hypertensive form of this disease.
• Bronchopulmonary dysplasia - damage to the bronchi and lungs by air blown by a ventilator, which was connected in order to resuscitate a newborn.
• Pheochromocytoma.
• Takayasu's disease is a lesion of the aorta and large branches extending from it due to an attack on the walls of these vessels by its own immunity.
• Periarteritis nodosa - inflammation of the walls of small and medium-sized arteries, resulting in the formation of saccular protrusions - aneurysms.

Pulmonary hypertension is not a type of arterial hypertension. This is a life-threatening condition in which pressure in the pulmonary artery rises. This is the name of 2 vessels into which the pulmonary trunk is divided (a vessel emanating from the right ventricle of the heart). The right pulmonary artery carries oxygen-depleted blood to the right lung, the left to the left.

Pulmonary hypertension develops most often in women aged 30-40 years and, gradually progressing, is a life-threatening condition, leading to disruption of the right ventricle and premature death. It occurs due to hereditary causes, and due to diseases of the connective tissue, and heart defects. In some cases, its cause cannot be found. Manifested by shortness of breath, fainting, fatigue, dry cough. In severe stages, the heart rhythm is disturbed, hemoptysis appears.

Stages, grades and risk factors

In order to find treatment for people suffering from hypertension, doctors have come up with a classification of hypertension by stages and degrees. We will present it in the form of tables.

Stages of hypertension

The stages of hypertension indicate how much the internal organs have suffered from constantly elevated pressure:

Blood pressure numbers at any stage are above 140/90 mm Hg. Art.

Treatment of the initial stage of hypertension is mainly aimed at changing lifestyle:, inclusion in the daily regimen of mandatory,. Whereas stage 2 and 3 hypertension should already be treated with the use of. Their dose and, accordingly, side effects can be reduced if you help the body restore blood pressure in a natural way, for example, by giving it additional help.

Degrees of hypertension

The degrees of development of hypertension indicate how high blood pressure is:

The degree is established without taking pressure-reducing drugs. To do this, in a person who is forced to take drugs that reduce pressure, it is necessary to reduce their dose or completely cancel them.

The degree of hypertension is judged by the figure of that pressure (“upper” or “lower”), which is greater.

Sometimes 4 degrees of hypertension are isolated. It is treated as isolated systolic hypertension. In any case, this refers to the state when only the upper pressure is increased (above 140 mm Hg), while the lower one is within the normal range - up to 90 mm Hg. This condition is most often recorded in the elderly (associated with a decrease in the elasticity of the aorta). Occurring in young people, isolated systolic hypertension indicates that it is necessary to examine the thyroid gland: this is how hyperthyroidism “behaves” (an increase in the amount of thyroid hormones produced).

Definition of risk

There is also a classification by risk groups. The higher the number after the word “risk”, the higher the likelihood that a dangerous disease will develop in the coming years.

There are 4 levels of risk:

1. At risk 1 (low), the probability of developing a stroke or heart attack in the next 10 years is less than 15%;
2. At risk 2 (medium), this probability in the next 10 years is 15-20%;
3. At risk 3 (high) - 20-30%;
4. At risk 4 (very high) - more than 30%.

To assess the risk, target organ damage is also assessed, which is either present or absent. Target organ damage is assessed by:

• hypertrophy (enlargement) of the left ventricle. It is assessed by electrocardiogram (ECG) and ultrasound of the heart;
• kidney damage: for this, the presence of protein in the general urine test (normally it should not be), as well as blood creatinine (normally it should be less than 110 µmol / l) is assessed.

The third criterion that is evaluated to determine the risk factor is comorbidities:

1. Diabetes mellitus: it is established if fasting plasma glucose is more than 7 mmol / l (126 mg / dl), and 2 hours after ingestion of 75 g of glucose - more than 11.1 mmol / l (200 mg / dl);
2. metabolic syndrome. This diagnosis is established if there are at least 3 of the following criteria, and body weight is necessarily considered one of them:

• HDL cholesterol less than 1.03 mmol/l (or less than 40 mg/dl);
• systolic blood pressure more than 130 mm Hg. Art. and/or diastolic pressure greater than or equal to 85 mm Hg. Art.;
• glucose over 5.6 mmol/l (100 mg/dl);
• waist circumference for men is more than or equal to 94 cm, for women - more than or equal to 80 cm.

Setting the degree of risk:

There is no direct relationship between the degree of pressure increase and the risk group, but at a high stage, the risk will also be high. For example, it could be hypertension 1st stage 2nd degree risk 3(that is, there is no damage to target organs, pressure is 160-179 / 100-109 mm Hg, but the probability of heart attack / stroke is 20-30%), and this risk can be both 1 and 2. But if stage 2 or 3, then the risk cannot be lower than 2.

Examples and interpretation of diagnoses - what do they mean?

What it is - hypertension stage 2 stage 2 risk 3?:

• blood pressure 160-179 / 100-109 mm Hg. Art.
• there are problems with the heart, determined by ultrasound of the heart, or there is a violation of the kidneys (according to analyzes), or there is a violation in the fundus, but there is no visual impairment;
• there may be either diabetes mellitus, or atherosclerotic plaques are found in some vessel;
• in 20-30% of cases, either a stroke or a heart attack will develop in the next 10 years.

3 stages 2 degree risk 3? Here, in addition to the parameters indicated above, there are also complications of hypertension: angina pectoris, myocardial infarction, chronic heart or kidney failure, retinal vascular damage.

Hypertonic disease 3 degrees 3 stages risk 3- everything is the same as for the previous case, only the blood pressure numbers are more than 180/110 mm Hg. Art.

What is hypertension 2 stages 2 degree risk 4? Blood pressure 160-179/100-109 mm Hg. Art., target organs are affected, there is diabetes mellitus or metabolic syndrome.

It even happens when 1st degree hypertension, when the pressure is 140-159 / 85-99 mm Hg. Art., already available 3 stage, that is, life-threatening complications (angina pectoris, myocardial infarction, heart or kidney failure) developed, which, together with diabetes mellitus or metabolic syndrome, caused risk 4.

It does not depend on how much the pressure rises (the degree of hypertension), but on what complications the constantly elevated pressure caused:

Stage 1 hypertension

In this case, there are no lesions of target organs, therefore, disability is not given. But the cardiologist gives recommendations to the person, which he must take to the workplace, where it is written that he has certain limitations:

• heavy physical and emotional stress is contraindicated;
• cannot work on the night shift;
• work in conditions of intense noise, vibration is prohibited;
• it is impossible to work at height, especially when a person serves electrical networks or electrical units;
• it is impossible to perform those types of work in which a sudden loss of consciousness can create an emergency (for example, public transport drivers, crane operators);
• prohibited those types of work in which there is a change in temperature regimes (bath attendants, physiotherapists).

Stage 2 hypertension

In this case, target organ damage is implied, which worsens the quality of life. Therefore, at the VTEK (MSEC) - a medical labor or medical and sanitary expert commission - he is given a III group of disability. At the same time, those restrictions that are indicated for stage 1 of hypertension remain. The working day for such a person can be no more than 7 hours.

To qualify for a disability, you must:

• submit an application addressed to the chief physician of the medical institution where MSEC is carried out;
• get a referral to a commission at a polyclinic at the place of residence;
• validate the group annually.

Stage 3 hypertension

Diagnosis of hypertension 3 stages no matter how high the pressure is 2 degrees or more, implies damage to the brain, heart, eyes, kidneys (especially if there is a combination with diabetes mellitus or metabolic syndrome, which makes it risk 4), which significantly limits the ability to work. Because of this, a person can receive II or even I group of disability.

Consider the "relationship" of hypertension and the army, regulated by Decree of the Government of the Russian Federation of 04.07.2013 N 565 "On approval of the Regulations on military medical expertise", Article 43:

Do they take to the army with hypertension if the increase in pressure is associated with disorders of the autonomic (which controls the internal organs) nervous system: sweating of the hands, variability in pulse and pressure when changing body position)? In this case, a medical examination is carried out under article 47, on the basis of which either category “C” or “B” is issued (“B” - fit with minor restrictions).

If, in addition to hypertension, the conscript has other diseases, they will be examined separately.

Can hypertension be completely cured? This is possible if eliminated - those that are detailed above. To do this, you need to carefully examine, if one doctor did not help to find the cause - consult with him, which narrow specialist should still go to. Indeed, in some cases, it is possible to remove the tumor or expand the diameter of the vessels with a stent - and permanently get rid of painful attacks and reduce the risk of life-threatening diseases (heart attack, stroke).

Do not forget: a number of causes of hypertension can be eliminated by giving the body an additional message. This is called, and helps to speed up the removal of damaged and used cells. In addition, it resumes immune responses and helps to carry out reactions at the tissue level (it will act like a massage at the cellular level, improving the connection between the necessary substances). As a result, the body will not need to increase the pressure.

The phonation procedure with the help can be performed while sitting comfortably on the bed. The devices do not take up much space, are easy to use, and their cost is quite affordable for the general population. Its use is cost-effective: this way you make a one-time purchase, instead of a permanent purchase of drugs, and, in addition, the device can treat not only hypertension, but also other diseases, and can be used by all family members). Phonation is also useful after the elimination of hypertension: the procedure will increase the tone and resources of the body. With the help you can carry out a general recovery.

The effectiveness of the use of devices is confirmed.

For the treatment of stage 1 hypertension, such exposure may be quite enough, but when a complication has already developed, or hypertension is accompanied by diabetes mellitus or metabolic syndrome, therapy should be agreed with a cardiologist.

Bibliography

1. Guide to cardiology: Textbook in 3 volumes / Ed. G.I. Storozhakova, A.A. Gorbachenkov. - 2008 - Vol. 1. - 672 p.
2. Internal diseases in 2 volumes: textbook / Ed. ON THE. Mukhina, V.S. Moiseeva, A.I. Martynov - 2010 - 1264 p.
3. Aleksandrov A.A., Kislyak O.A., Leontieva I.V. Diagnosis, treatment and prevention of arterial hypertension in children and adolescents. - K., 2008 - 37 p.
4. Tkachenko B.I. normal human physiology. - M, 2005
5. . Military Medical Academy. CM. Kirov, St. Petersburg. 1998
6. P. A. Novoselsky, V. V. Chepenko (Vladimir Regional Hospital).
7. P. A. Novoselsky (Vladimir Regional Hospital).
8. . Military Medical Academy. CM. Kirov, St. Petersburg, 2003
9. . State Medical Academy. I.I. Mechnikov, St. Petersburg. 2003
10. Dissertation of the candidate of medical sciences Svizhenko A.A., Moscow, 2009
11. Order of the Ministry of Labor and Social Protection of the Russian Federation of December 17, 2015 No. 1024n.
12. Decree of the Government of the Russian Federation of 04.07.2013 No. 565 “On Approval of the Regulations on Military Medical Expertise”.
13. Wikipedia.

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