The concept of antihypertensive therapy includes a complex of pharmacological and nonpharmacological measures aimed at stabilizing blood pressure values and preventing complications of hypertension. This is a combined regimen that includes drugs and recommendations for the modification of risk factors, individually selected for the patient. Their implementation provides stabilization of pressure indicators, reducing the actual frequency of complications or their maximum delay, improving the quality of life of the patient.
Introduction
Paradoxically! If everything is fine in words and in printed materials of the press, then statistics reveal many problems. Among them are the refusal to follow medical recommendations, the lack of discipline in the patient, the assumption of concessions and the inability to fully follow the appointments. This is partly due to the unjustifiably low level of trust in medical workers, the abundance of media misinformation about cardiovascular diseases, medicine and beauty. Partially correct this situation, to reveal the concept of antihypertensive therapy for the patient, to characterize the pharmacological treatment and approaches to its improvement in different categories of patients, and this publication is intended.
This voluminous material provides complete information about the treatment of hypertension with pharmacological and non-pharmacological agents. Combination therapy with antihypertensive drugs is most fully considered in the context of the initially set treatment goals. We advise you to carefully and thoughtfully study the article from beginning to end and use it as a material explaining the need for the treatment of hypertension and methods of therapy.
Any of the information below is not new to the therapist or cardiologist, but will be very useful to the patient. It will be impossible to draw the correct conclusions with a cursory review or “vertical” reading of the material. Any theses of this publication should not be taken out of context and presented as advice to other patients.
Prescribing drugs or selecting antihypertensive therapy is a difficult job, the success of which depends on a competent professional interpretation of risk factors. This is an individual specialist work with each patient, the result of which should be a treatment regimen that avoids high pressure values. It is important that simple, understandable and universal recommendations for the selection of antihypertensive treatment for each patient do not exist.
Objectives of Antihypertensive Therapy
One of the many mistakes of patients is the lack of a solid idea of why the selection of antihypertensive therapy is carried out. Patients refuse to think about why they need to treat hypertension and stabilize blood pressure. As a result, only a few adequately understand why all this is necessary and what awaits them in case of refusal of therapy. So, the first goal, to achieve which hypotensive therapy is carried out, is to improve the quality of life. It is achieved by:
- reducing the number of episodes of malaise, headaches, dizziness;
- reducing the number of hypertensive crises with the need for emergency care with the involvement of medical workers;
- reduction of periods of temporary disability;
- increased tolerance to physical activity;
- eliminate painful psychological sensations from the presence of symptoms of hypertension, increase comfort through stabilization;
- elimination or maximum reduction of episodes of complicated crises of hypertension (nosebleeds, cerebral infarction and myocardium).
The second goal of antihypertensive drug therapy is to increase life expectancy. Although it should be more correctly formulated as restoring the former, which took place before the development of the disease, the potential for life expectancy due to:
- decrease in the rate of hypertrophic and dilated myocardial transformation;
- reduce the likelihood and actual frequency of cases of atrial fibrillation;
- reducing the likelihood and frequency, reducing severity, or completely preventing the development of chronic kidney disease;
- preventing or delaying terrible complications of hypertension (myocardial infarction, cerebral infarction, intracerebral hemorrhage);
- reduce the rate of development of congestive heart failure.
The third goal of treatment is pursued in pregnant women and is associated with a decrease in the total number of complications and deviations during gestation during childbirth or in the recovery period. High-quality and adequate in the average numbers of blood pressure antihypertensive therapy during pregnancy is a vital necessity for the normal development of the fetus and its birth.
Therapy Approaches
Antihypertensive therapy should be carried out systemically and in a balanced manner. This means that the treatment requires an adequate consideration of the existing risk factors for a particular patient and the likelihood of developing related complications. The ability to simultaneously influence the mechanism of development of hypertension, to prevent or reduce the frequency of possible complications, to reduce the likelihood of worsening the course of hypertension and to heal the patient, has become the basis of modern therapeutic regimens. And in this context, you can consider such a thing as combination antihypertensive therapy. It includes both pharmacological and non-pharmacological directions.
The pharmacological treatment of hypertension is the use of drugs that affect specific biochemical and physical mechanisms of blood pressure formation. Non-drug therapy is a complex of organizational measures aimed at eliminating any factors (excess weight, smoking, insulin resistance, physical inactivity) that can cause hypertension, aggravate its course or accelerate the development of complications.
Treatment tactics
Depending on the initial pressure figures and the presence of risk factors, a specific treatment tactic is chosen on a stratification scale. It can consist only of non-pharmacological measures if, on the basis of daily monitoring, hypertension of the first degree is exposed without risk factors. At this stage of the development of the disease, the main thing for the patient is the systematic monitoring of blood pressure.
Unfortunately, in this publication, it is impossible to explain to each patient the principles of antihypertensive therapy on the basis of stratification scales for the risk of arterial hypertension. In addition, their assessment is needed to determine the time of initiation of drug treatment. This is a task for a specially trained and trained employee, while the patient will only need to follow the doctor’s recommendations in a disciplined manner.
Transition to medical treatment
In case of inadequate reduction in pressure figures as a result of weight loss, smoking cessation and modification of the diet, antihypertensive drugs are prescribed. Their list will be discussed below, however, it should be understood that drug therapy will never be sufficient if the treatment regimen is inadequately followed and the medication is skipped. Also, drug therapy is always prescribed along with non-drug methods of treatment.
It is noteworthy that antihypertensive therapy in elderly patients is always based on drugs. This is explained by already existing risk factors for coronary heart disease with an inevitable outcome in heart failure. The drugs used for hypertension significantly slow down the rate of development of cardiac insufficiency, which justifies this approach even from the moment of primary detection of hypertension in a patient older than 50 years.
Priorities in the treatment of hypertension
The effectiveness of non-medications that prevent the development of complications and help control blood pressure in the target numbers is very high. Their contribution to lowering the average pressure with adequate disciplined follow-up by the patient is 20–40%. However, with hypertension of the 2nd and 3rd degree, pharmacological treatment is more effective, since it allows you to lower the pressure figures, as they say, here and now.
For this reason, with hypertension of the 1st degree without complications, you can treat the patient without taking medications. At the 2nd and 3rd degrees of hypertension, antihypertensive drugs used in therapy are simply necessary to maintain working capacity and comfortable life. In this case, priority is given to the appointment of 2, 3 or more antihypertensive drugs from different pharmacological groups in low doses instead of using one type of medicine in high doses. Several drugs used in the same treatment regimen affect the same or more mechanisms for increasing blood pressure. Because of this, the drugs potentiate (mutually reinforce) the effect of each other, which provides a stronger effect at low doses.
In the case of monotherapy, one drug, even in high doses, affects only one mechanism of blood pressure formation. Therefore, its effectiveness will always be lower, and the cost is higher (drugs in medium and high doses always cost 50-80% more expensive). In addition, due to the use of one drug in high doses, the body quickly adapts to xenobiotics and accelerates its administration.
With monotherapy, the speed of the so-called addiction of the body to the drug and the “slipping away” of the effect of therapy is always faster than in the case of prescribing different-class drugs. Therefore, with it, correction of antihypertensive therapy with a change of drugs is often required. This creates the prerequisites for the fact that patients form a large list of drugs that, in the case of it, are "no longer working." Although they are effective, they just need to be combined correctly.
Hypertensive crisis
Hypertensive crisis is an episode of pressure increase to high numbers during treatment with the appearance of stereotypical symptoms. Among the symptoms most often there is a pressing headache, discomfort in the parietal and occipital region, flickering flies in front of the eyes, sometimes dizziness. Less commonly, a hypertensive crisis develops with complication and requires hospitalization.
It is important that even against the background of effective therapy, when the average numbers of blood pressure meet the standards, a crisis can occur (and periodically). It appears in two versions: neurohumoral and water-salt. The first develops rapidly, within 1-3 hours after stress or a heavy load, and the second - gradually, in 1-3 days with excessive accumulation of fluid in the body.
The crisis is stopped with specific antihypertensive agents. For example, with the neurohumoral variant of the crisis, it is reasonable to take the drug “Captopril” and “Propranolol” or seek medical help. In case of water-salt crisis, the most appropriate method is to take loop diuretics (Furosemide or Torasemide) together with Captopril.
It is important that antihypertensive therapy for hypertensive crisis depends on the presence of complications. The uncomplicated option is stopped on its own according to the above scheme, and the complicated one requires calling an ambulance or a visit to the admission department of inpatient healthcare facilities. Crisis more than 1 time per week indicates the failure of the current antihypertensive regimen, which requires correction after going to the doctor.
Rare crises that occur with a frequency of less than 1 time in 1-2 months do not require correction of the main treatment. Intervention in an effective combination therapy of antihypertensive therapy in elderly patients is carried out in the last turn, only upon receipt of evidence of "slipping" effect, with poor tolerance or allergies.
Groups of drugs for the treatment of hypertension
Among antihypertensive drugs, a huge number of trade names, which are neither necessary nor possible to list. In the context of this publication, it is appropriate to highlight the main classes of drugs and briefly describe them.
1st group - angiotensin - converting enzyme inhibitors . The ACE inhibitor group is represented by such drugs as Enalapril, Captopril, Lisinopril, Perindopril, Ramipril, and Quinapril. These are the main drugs for the treatment of hypertension, which have the ability to slow down the development of myocardial fibrosis and delay the onset of heart failure, atrial fibrillation, and renal failure.
2nd group - angiotensin receptor blockers. The drugs of the group are similar in effectiveness to ACE inhibitors, since they exploit the same angiotensinogen mechanism. However, ARBs are not blockers of the enzyme, but inactivators of the angiotensin receptor. In terms of effectiveness, they are slightly inferior to ACE inhibitors, but they also slow down the development of heart failure and chronic renal failure. The following drugs are presented in this group: “Losartan”, “Valsartan”, “Candesartan”, “Telmisartan”.
3rd group - diuretics (loop and thiazide). Hypothiazide, Indapofon and Chlortalidone are relatively weak thiazide diuretics that are convenient for continuous use. Furosemide and Torasemide loop diuretics are well suited for stopping crises, although they can also be prescribed on an ongoing basis, especially with already developed congestive heart failure. In diuretics, their ability to increase the effectiveness of ARBs and ACE inhibitors is of particular value. Antihypertensive therapy during pregnancy involves the use of diuretics in the last turn, with the ineffectiveness of other drugs, because of their ability to reduce placental blood flow, while in other patients it is the main (and almost always mandatory) drug for treating hypertension.
4th group - adrenergic blockers: Metoprolol, Bisoprolol, Carvedilol, Propranolol. The latter drug is suitable for stopping crises due to its relatively quick action and effect on alpha receptors. The remaining drugs from this list help control blood pressure, but are not essential in the antihypertensive regimen. Doctors value their proven ability to increase the life expectancy of patients with heart failure while taking ACE inhibitors and diuretics.
5th group - calcium channel blockers: Amlodipine, Lercanidipine, Nifedipine, Diltiazem. This group of drugs is widely used in the treatment of hypertension due to the possibility of administration by pregnant patients. Amlodipine has a nephroprotection effect that, together with the use of ACE inhibitors (or ARBs) and diuretics, slows down the development of chronic renal failure in patients with malignant hypertension in non-pregnant patients.
6th group - other drugs. Heterogeneous drugs that have been used as antihypertensives and have heterogeneous mechanisms of action should be indicated here. These are Moxonidine, Clonidine, Urapidil, Methyldopa and others. A complete list of drugs is always present by a doctor and does not require memorization. It is much more beneficial if each patient will remember their antihypertensive regimen and those drugs that have been used successfully or unsuccessfully before.
Antihypertensive therapy during pregnancy
During pregnancy, the most commonly prescribed drugs are Methyldopa (category B), Amlodipine (category C), Nifedipine (category C), Pindolol (category B), Diltiazem (category C). In this case, the independent choice of drugs by a pregnant woman is unacceptable because of the need for primary diagnosis of increased blood pressure. Diagnosis is required to exclude preeclampsia and eclampsia - dangerous pathologies of pregnancy. The selection of treatment will be carried out by the attending physician, and any increase in blood pressure not observed previously (before pregnancy) in a pregnant woman should be carefully studied.
Antihypertensive therapy for lactation is subject to strict rules: in the first case, if blood pressure is not higher than 150/95, breastfeeding can be continued without taking antihypertensive drugs. In the second case, with blood pressure in the range of 150 / 95-179 / 109, low-dose use of antihypertensive drugs is practiced (the dose is prescribed by a doctor and monitored under the supervision of medical staff) with continued breastfeeding.
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In patients with diabetes mellitus and chronic renal failure, there is often a damage to the organ of vision associated with both retinal microangiopathy and its hypertensive lesion. An increase in IOP to 28 with or without antihypertensive therapy indicates a tendency to develop glaucoma. This disease is not associated with arterial hypertension and damage to the retina, it is a lesion of the optic nerve as a result of an increase in intraocular pressure.
The value of 28 mmHg is considered borderline and characterizes only the tendency to the development of glaucoma. Values above 30-33 mmHg are a clear sign of glaucoma, which together with diabetes, chronic renal failure and hypertension can accelerate the loss of vision in a patient. It should be treated along with the main pathologies of the cardiovascular and urinary systems.