Arterial hypertension. Risk assessment in arterial hypertension and modern aspects of antihypertensive therapy stage of hypertension

For citation: Ivashkin V.T., Kuznetsov E.N. Risk assessment in arterial hypertension and modern aspects of antihypertensive therapy // BC. 1999. No. 14. S. 635

Department of propaedeutics of internal diseases THEM. Sechenov

Arterial hypertension (AH) is one of the main risk factors for the development of coronary heart disease (CHD), including myocardial infarction, and the main cause of cerebrovascular diseases (in particular, stroke). In Russia, the share of mortality from cardiovascular diseases in total mortality is 53.5%, while 48% of this proportion falls on cases caused by coronary artery disease, and 35.2% - on cerebrovascular diseases. It is important to note that in the working-age population, cerebrovascular diseases were detected in 20% of individuals, of which 65% suffer from hypertension, and among patients with cerebrovascular accident, more than 60% have mild hypertension. Strokes in Russia occur 4 times more often than in the US and Western Europe, although the mean arterial pressure (BP) in these populations differs slightly (WHO/IOAG, 1993) . This explains the importance of early diagnosis and treatment of hypertension, which helps prevent or slow down the development of organ damage and improve the patient's prognosis.

As stated in the Report of the WHO Expert Committee on the Control of Arterial Hypertension (1996), Examination of a patient with a newly diagnosed increase in blood pressure includes the following tasks:

Thus, the process of diagnosing hypertension consists of a fairly simple first stage - detection of elevated blood pressure and a more complex next one - identifying the cause of the disease (symptomatic hypertension) and determining the prognosis of the disease (assessment of involvement of target organs in the pathological process, assessment of other risk factors).

Until recently, the diagnosis of hypertension was made in cases where repeated measurements of systolic blood pressure (SBP) were at least 160 mm Hg. or diastolic blood pressure (DBP) - not less than 95 mm Hg. (WHO, 1978). These recommendations were based on the results of a cross-sectional (one-shot) survey of large populations. At the same time, AH was defined as a condition in which the level of blood pressure exceeds the average values ​​of this indicator in this age group by an amount greater than twice the standard deviation.

In the early 1990s, the criteria for hypertension were revised in the direction of their tightening. According to modern concepts, arterial hypertension is a persistent increase in SAD-140 mm Hg. or DADі90 mm Hg. (Table 1).

In people with increased emotionality as a result of a stress reaction to the measurement, inflated numbers may be registered that do not reflect the true state. As a result, misdiagnosis of hypertension is possible. To avoid this condition, called the “white coat” syndrome, rules for measuring blood pressure have been developed. Blood pressure should be measured in the patient's sitting position, after 5 minutes of rest, 3 times with an interval of 2-3 minutes. True blood pressure is calculated as the arithmetic mean between the two closest values.

BP below 140/90 mm Hg. Art. conventionally considered normal, but this level of blood pressure cannot be considered optimal. , given the likelihood of subsequent development of coronary artery disease and other cardiovascular diseases. The optimal level of blood pressure in terms of the risk of developing cardiovascular diseases was established after the completion of several long-term studies that included large populations. The largest of these prospective studies was the 6-year MRFIT (Multiple Risk Factor Intervention Trial, 1986). The MRFIT study included 356,222 men aged 35 to 57 years without a history of myocardial infarction. Analysis of the obtained data showed that The 6-year risk of developing fatal coronary artery disease is lowest among men with baseline DBP below 75 mm Hg. Art. and SBP below 115 mm Hg. Mortality from CAD is increased at DBP levels of 80 to 89 mmHg. and SBP from 115 to 139 mm Hg. Art., which are conventionally considered “normal”. So, with an initial DBP of 85-89 mm Hg. Art. the risk of developing fatal coronary artery disease is 56% greater than in individuals with DBP below 75 mm Hg. Art. With an initial SBP of 135-139 mm Hg. Art. the probability of death from coronary artery disease is 89% higher than in individuals with SBP below 115 mm Hg. Art. Therefore, it is not surprising if in the future the criteria for diagnosing hypertension will be even more stringent.

The tactics of managing a patient when he has elevated BP numbers are discussed in detail in the VI report of the US Joint National Committee on the Prevention, Detection and Treatment of High BP (JNC-VI, 1997) (Table 2).

Similar recommendations for monitoring patients after the first measurement of blood pressure are given by the WHO Expert Committee on the control of blood pressure (1996). Depending on the specific situation (historical blood pressure levels, presence of organ damage and other cardiovascular diseases and their risk factors), the blood pressure monitoring plan should be adjusted.

Establishing the final diagnosis of hypertension with classification according to the level of blood pressure, determining the risk of developing cardiovascular complications based on the involvement of target organs in the pathological process and the presence of other risk factors means the start of treatment for the patient. Since this process can be extended in time, in some cases (severe hypertension, numerous risk factors and other circumstances), diagnosis and treatment go hand in hand.

The goal of modern antihypertensive therapy is cardio- and vasoprotection, leading to a reduction in the incidence of complications and death. Of great importance is the early diagnosis of hypertension in order to provide an effective impact before changes in target organs occur.

If elevated blood pressure values ​​are detected, the patient is given lifestyle advice , which are the first step in the treatment of hypertension (Table 3).

According to the study TOMHS (Treatment of Mild Hypertension Study, 1993), subject to the recommendations given in Table. 3, in patients with hypertension (AH) without the use of drugs, it was possible to significantly reduce blood pressure (by an average of 9.1/8.6 mm Hg compared with 13.4/12.3 mm Hg among patients who additionally received one of the effective antihypertensive drugs). As the TOMHS study showed, as a result of lifestyle changes, it is possible not only to reduce blood pressure, but to cause the regression of left ventricular hypertrophy (LV.) . Thus, in the control group of patients with AH over 4.4 years of observation, the mass of the LV myocardium decreased by 27 ± 2 g, while in the groups of patients who additionally received antihypertensive drugs, by 26 ± 1 g.

The JNC-VI report states that limiting lifestyle changes is acceptable only in people with blood pressure less than 160/100 mmHg, who have neither target organ damage, nor cardiovascular disease, nor diabetes mellitus. In all other cases, antihypertensive drugs should be given in combination with lifestyle changes. In patients with heart failure, renal failure, or diabetes mellitus, antihypertensive drugs are recommended even at blood pressure levels in the range of 130–136/85–89 mmHg. rt. Art. (Table 4).

In addition to lifestyle changes and drug therapy, it is necessary to mention non-drug therapy, which includes normalized physical activity, autogenic training, behavioral therapy using the biofeedback method, muscle relaxation, acupuncture, electrosleep and physiological bioacoustic effects (music) .

With a good effect from the use of an antihypertensive drug, many patients continue to lead a former lifestyle, considering it easier to take one tablet of a prolonged drug in the morning than following recommendations that deprive the “joys of life”. It is necessary to conduct conversations with patients, explaining that with lifestyle changes, doses of the drugs taken may be reduced over time.

It is necessary to dwell separately on the issue of blood pressure level to aim for in the treatment of hypertension . Until the mid-1980s, there was an opinion that lowering blood pressure in elderly people with hypertension was not only not necessary, but it could cause undesirable consequences. At present it is convincing demonstrated a positive result in the treatment of hypertension in the elderly. The SHEP, STOP-Hypertension, and MRC trials have convincingly shown a reduction in morbidity and mortality in these patients.

Situations when a doctor is forced to admit an increased level of blood pressure in a patient with HA are relatively rare and, as a rule, refer to patients with a long and severe disease. Overwhelmingly In most cases of HD, one should strive to lower blood pressure to a level below 135-140 / 85-90 mm Hg. Art. In patients younger than 60 years of age with mild hypertension, as well as in patients with diabetes mellitus or kidney disease, blood pressure should be maintained at 120-130/80 mm Hg. Art. . However, uncompromising “normalization” of blood pressure may be unfavorable in elderly patients and in various forms of local circulatory failure (cerebral, coronary, renal, peripheral), especially if hypertension is partly compensatory. Statistically, this is described as an iota-like dependence of vascular complications on the level of blood pressure. In this age group, atherosclerotic changes are more pronounced, and with a sharp decrease in blood pressure, ischemia may increase (for example, ischemic strokes against the background of clinically significant atherosclerosis of the carotid arteries). The pressure in such patients should be reduced gradually, assessing the general well-being and the state of regional blood flow. The principle of "do no harm" in such patients is especially relevant. Besides, comorbidity needs to be taken into account : for example, the appointment of calcium channel antagonists (rather than b-blockers) with signs of obliterating atherosclerosis of the vessels of the lower extremities; reduction in the dosage of drugs excreted by the kidneys, in the presence of signs of renal failure, etc.

When choosing drugs, one should, if possible, give preference to those that do not cause a significant deterioration in the quality of life of the patient and which can be taken 1 time per day. Otherwise, it is very likely that an asymptomatic patient with HD will not take a drug that worsens his well-being. A modern antihypertensive drug should have a sufficient duration of action, stability of the effect, and a minimum of side effects. We should not forget about its price.

The relative value of drugs is determined at the present stage by carefully designed multicentric studies, the criteria are absolute indicators: a decrease in mortality from cardiovascular diseases (taking into account total mortality), the number of non-fatal complications, objective indicators of the impact on the quality of life of patients and on the course of concomitant diseases.

Antihypertensive drugs suitable for both long-term monotherapy and combination therapy are:. thiazide and thiazide-like diuretics;

All of these drugs can be used to start hypertension monotherapy. In addition, it is necessary to mention the recently appeared group imidazoline receptor blockers (moxonidine) , close in action to central a 2 -adrenergic receptor agonists, however, unlike the latter, they are better tolerated and favorably affect carbohydrate metabolism, which is especially important in patients with diabetes mellitus.

Loop diuretics are rarely used to treat hypertension. Potassium-sparing diuretics (amiloride, spironolactone, triamterene), direct vodilators (hydralazine, minoxidil) and sympatholytics of central and peripheral action (reserpine and guanethidine), as well as central a 2 -adrenergic agonists, which have many side effects, have been used in recent years only in combination with other antihypertensive drugs.

The expansion of the spectrum of antihypertensive drugs has allowed some authors to put forward the concept of individualized choice of first-line drugs in the treatment of hypertension . It should be noted that it is not the “strength” of the drug that is decisive, since contrary to popular belief new antihypertensive agents are not significantly superior to diuretics and b -blockers for antihypertensive activity . Given the similar efficacy of antihypertensive drugs, their choice should primarily take into account tolerability, ease of use, effects on LV hypertrophy, kidney function, metabolism, etc. When prescribing treatment, it is also necessary to take into account the allergic history.

In accordance with modern requirements for antihypertensive therapy, it is also necessary individual selection of the drug taking into account risk factors . In past years, until the early 90s, hypertension was considered only as a problem of lowering blood pressure. Today, hypertension should be considered and treated in a single complex with risk factors for cardiovascular disease.

Ultrasound or x-ray signs of atherosclerotic plaque (carotid iliac and femoral arteries, aorta);

The presence of several risk factors in a patient increases the risk of developing cardiovascular complications. The risk increases especially sharply with a combination of hypertension, obesity, hypercholesterolemia and hyperglycemia, known as the “deadly quartet” (Table 5).

Comparison of blood pressure levels and factors influencing the prognosis in hypertension allows the doctor to determine the risk of complications in patients with elevated blood pressure, which is an important factor in choosing a regimen and timing of treatment. However, even with such a balanced and balanced approach to the treatment of hypertension, monotherapy does not normalize blood pressure in all patients. If antihypertensive therapy is ineffective, the drug taken should be changed or switched from mono- to combination therapy. When choosing drugs for combination therapy of hypertension, it is important to take into account the additional pharmacological properties of these drugs, which may be useful for the treatment of concomitant diseases or syndromes (Table 6).

Speaking about the adequacy of antihypertensive therapy, one cannot help but dwell on modern methods for monitoring its effectiveness. In recent years, medical practice has increasingly included blood pressure monitoring systems . Compact wearable monitors based on the Korotkoff method and/or using the oscillometric method allowed doctors to monitor not only blood pressure at night (bedside monitors also provide such an opportunity), but also in the patient's usual conditions, during physical and mental stress. In addition, the accumulated experience made it possible to separate patients depending on the nature of daily fluctuations in blood pressure into groups in which the risk of developing cardiovascular complications was significantly different.

. Dippe s - persons with a normal nocturnal decrease in blood pressure (by 10-22%)- 60-80% of patients with essential hypertension (EAH). This group has the lowest risk of complications.

. Over-dipper, or extreme-dippers - persons with an excessive nighttime drop in blood pressure (more than 22%)- up to 22% of patients with EAH.

. Night-peake s - persons with nocturnal hypertension in which nighttime blood pressure exceeds daytime - 3-5% of patients with EAH.

Disturbed circadian rhythm of blood pressure in EAH is observed in 10-15%, and in symptomatic hypertension and some other conditions (sleep apnea syndrome, condition after kidney or heart transplantation, eclampsia, diabetic or uremic neuropathy, congestive heart failure, widespread atherosclerosis in the elderly , normotonics with aggravated heredity for hypertension, impaired glucose tolerance) - in 50-95% of patients, which allows the use daily BP index (or the degree of nocturnal decrease in blood pressure) as an important diagnostic and prognostic criterion.

The cumulative analysis of national projects and individual studies conducted in the last 5 years allowed J. Staessen et al. (1998) to propose the following standards for the average values ​​of blood pressure according to daily monitoring data (Table 7).

Taking into account the high consistency of the results of individual national studies, the proposed values ​​can be taken as base ones in other countries as well.

Currently, large-scale studies are ongoing on groups of healthy volunteers to clarify the levels of average daily, average daily and average night blood pressure, corresponding to the norm.

In addition to the average blood pressure figures, an equally important indicator of the effectiveness of the therapy is time index , which indicates in what percentage of the time of the total duration of monitoring the blood pressure level was above normal values. Normally, it does not exceed 25%.

However, in some patients with severe hypertension, it is not possible to completely normalize blood pressure, the level of which decreases, but does not reach the norm, and the time index remains close to 100%. In such cases, to determine the effectiveness of therapy, in addition to indicators of the average daily, average daily and average night blood pressure, you can use area index , which is defined as the area on the graph of elevated blood pressure above the normal level. By the severity of the decrease in the area index in dynamics, one can judge the effect of antihypertensive therapy.

In conclusion, we note that the arsenal of modern antihypertensive drugs that allow you to quickly reduce and effectively control the level of blood pressure is quite large today. According to the results of multicenter studies, b - blockers and diuretics reduce the risk of developing cardiovascular diseases and complications and increase the life expectancy of patients. Of course, preference is given to selective prolonged b 1 -blockers and the thiazide-like diuretic indapamide, which has a much lesser effect on lipid and carbohydrate metabolism. There is evidence of a positive effect on the life expectancy of the application ACE inhibitors (enalapril) . Data on the results of the use of calcium antagonists are heterogeneous, some multicenter studies have not yet been completed, but today we can already say that long-acting drugs are preferred. The final analysis of ongoing multicenter studies will allow in the coming years to determine the place of each group of antihypertensive drugs in the treatment of hypertension.

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4. Rogoza A.N., Nikolsky V.P., Oshchepkova E.V., Epifanova O.N., Rukhinina N.K., Dmitriev V.V. Daily monitoring of blood pressure in hypertension (Methodological issues). 45.

5. Dahlof B., Lindholm L.H., Hansson L. et al. Morbidity and mortality in the Swedish trial in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991; 338:1281-5.

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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 and radically changing the diagnostic criteria for hypertension and target levels of blood pressure (BP). The purpose of this material is to provide information on the key provisions of the updated European recommendations.

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

Classification of blood pressure levels and definition of hypertension

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

Table 1 Classification of clinical BP

The criterion for hypertension according to the clinical measurement of blood pressure remained the level of 140 mm Hg. and above for systolic (SBP) and 90 mm Hg. and above - for diastolic (DBP). For home measurement of blood pressure, SBP of 135 mm Hg was retained as a criterion for hypertension. and above and / or DBP 85 mm Hg. and higher. According to the data of 24-hour blood pressure monitoring, the diagnostic cut-off points 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 monitoring (ABPM) and home BP measurement being emphasized. With regard to office BP measurement without the presence of medical personnel, it is recognized that there are currently insufficient data to recommend it for widespread clinical use.

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

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

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

Screening and diagnosis of hypertension

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

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

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

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

Figure 1. Algorithm for screening and diagnosing hypertension.

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

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

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

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

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

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

Stage 1 (uncomplicated) - there may be other risk factors, but there is no target organ damage. At this stage, patients with grade 3 hypertension, regardless of the number of risk factors, as well as patients with grade 2 hypertension with 3 or more risk factors, are classified as high-risk at this stage. The 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 (simultaneous with non-drug interventions or delayed) is determined by the level of clinical BP, the level of cardiovascular risk, the presence of target organ damage or cardiovascular disease (Fig. 2). As before, the immediate initiation of drug antihypertensive therapy is recommended for all patients with grade 2 and 3 hypertension, regardless of the level of cardiovascular risk (IA), while the target level of blood pressure should be achieved no later than 3 months.

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

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

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

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

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

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

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

Target BP levels

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

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

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

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

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 SBP levels in selected subpopulations of hypertensive patients

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

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

Lifestyle changes

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

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

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

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

Drug treatment strategy for hypertension

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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, central nervous system diseases, 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.

Dihydropyridine calcium antagonist - 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 the drug of choice for patients intolerant to ACE inhibitors and in the combination of hypertension 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 with a high risk of MI, death from coronary heart disease or atherosclerosis of other localization due to the presence of multiple risk factors (including smoking, hypertension, the presence of early coronary artery disease in the family), when a diet low in fats of animal origin was 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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Note:
National
clinical guidelines VNOK, 2010.

1. Hypertension, stage II. Degree
arterial hypertension 3. Dyslipidemia.
Left ventricular hypertrophy. Obesity II. Violation of tolerance
to glucose. Risk 4 (very high).

2. Hypertension, stage III. The degree of arterial hypertension
2. IHD. Angina pectoris, IIFC. Risk 4 (very high).
KhSIIIA st., IIIFK.

3. Hypertension, IIIst. Achieved AGI degree/
Obliterating atherosclerosis of the lower
limbs. Intermittent lameness.
Risk 4 (very high).

4. Pheochromocytoma of the right adrenal gland.
AG III Art. Hypertrophy
left ventricle. Risk 4 (very high).

Restrictions.

It should be recognized,
that all currently existing models
cardiovascular risk assessments have
restrictions. The meaning of defeat
target organs to calculate the total
risk depends on how carefully
assessed this lesion using
available survey methods. It is forbidden
not to mention also the conceptual
restrictions.

At
the formulation of the diagnosis of HD should indicate
stage, degree of disease and degree
risk. In individuals with newly diagnosed hypertension and
not receiving antihypertensive
therapy degree of arterial hypertension
pointing out is inappropriate. Besides,
it is recommended to detail the available
lesions of "target organs", factors
risk and associated clinical
states.

Algorithm for emergency care in hypertensive crisis

Hypertensive crises (HC) are subdivided
into two large groups - complicated
(life-threatening) uncomplicated
(non-life-threatening) GC.

Uncomplicated
hypertensive crisis,
despite the pronounced clinical
symptoms, not accompanied by acute
clinically significant dysfunction
target organs.

Complicated
hypertensive crisis
accompanied by life-threatening
complications, occurrence or aggravation
target organ damage and requires
decrease in blood pressure, starting from the first minutes, in
within minutes or hours of
help of parenteral drugs.

GC is considered complicated in the following
cases:

hypertonic
encephalopathy;

cerebral stroke
(MI);

acute coronary
syndrome (ACS);

acute left ventricular
failure;

exfoliating
aortic aneurysm;

hypertensive
crisis with pheochromocytoma;

preeclampsia or
eclampsia of pregnant women;

heavy
hypertension associated with subarachnoid
hemorrhage or head injury
brain;

AG
in postoperative patients and
the threat of bleeding;

hypertensive
crisis on the background of taking amphetamines, cocaine
and etc.

Hypertension, stage III. Degree of arterial hypertension III. Hypertrophy of the left
ventricle. Uncomplicated hypertensive
crisis dated 15.03.2010. Risk 4 (very high). ХСНIА st.,

Hypertensive
crisis in young and middle-aged people
in the early stages of HD development (I-II
stage) with a predominance in the clinic
neurovegetative symptoms. In that
case for stopping the crisis use
the following drugs:

propranolol
(anaprilin, obzidan, inderal) is introduced
3-5 ml of 0.1% solution (3-5 mg) in 10-15 ml
isotonic sodium chloride solution
intravenous bolus slowly.

Seduxen 2 ml (10
mg) per 10 ml isotonic solution
intravenous jet;

Dibazol 6-8 ml
0.5-1.0% solution is administered intravenously .;

Clonidine
is prescribed in a dose of 0.5-2 ml of a 0.1% solution
intravenously in 10-20 ml of physiological
solution, injected slowly over
3-5 min.

Hypertensive
crisis proceeding according to the type of vegetative
paroxysm
and accompanied by a feeling of fear,
anxiety, worry. These patients
shown the following medicinal
facilities:

droperidol 2 ml
0.25% solution intravenously 10 ml isotonic
sodium chloride solution;

pyrroxan 1-2 ml
1% solution in / m or subcutaneously;

chlorpromazine
1-2 ml of a 2.5% solution intramuscularly or
intravenously in 10 ml of saline
solution.

Hypertensive
crisis in the elderly.
proceed according to the type of cerebral ischemic
crises. With cerebral ischemic
crisis with angiospasm of the cerebral arteries
and the development of local cerebral ischemia are shown
antispasmodics and diuretics:

eufillin
5-10 ml of 2.4% solution in 10-20 ml of physiological
solution;

no-shpa 2-4 ml 2-%
solution intravenously;

lasix 40-60 mg
intravenous jet;

clonidine
1-2 ml of 0.1% solution intravenously per -20 ml
physiological solution;

hyperstat
(diazoxide) 20 ml intravenously. decline
BP in the first 5 minutes and persists
several hours.

Cerebral
angiodystonic crisis
with increased intracranial pressure.
In this situation, antispasmodics
contraindicated. Less desirable
also, intramuscular administration of sulphate
magnesium, because dehydration effect
weak, comes late (after 40 minutes),
infiltrates often occur.

Analgin
50% solution 2 ml intravenously

Caffeine
10% solution 2 ml subcutaneously or cordiamine
1-2 ml intravenously slowly

Clonidine
2-1 ml 0.1% solution intravenously slowly

Lasix
20-40 mg intravenous bolus

Nitroprusside
sodium (nanipruss) 50 mg IV
drip in 250 ml of 5% glucose solution.

Pentamine
5% solution 0.5-1ml with 1-2ml droperidol
intravenously drip in 50 ml of physiological
solution

Lasix 80-120 mg
intravenous bolus slowly or
drip.

Fentanyl
1 ml and 2-4 ml of a 0.25% solution of droperidol in 20
ml of 5% glucose solution intravenously
jet

Clonidine
1-2 ml of 0.1% solution intravenously per 20 ml
physiological solution.

myocardial ischemia.

low risk
(1)-less than 15%

Medium risk (2) –
15-20%

High risk (3) –
20-30%

Very tall
the risk is 30% or more.

For diagnostics
myocardial ischemia in AH patients with LVH
reserves have special procedures.
This diagnosis is particularly difficult because
how hypertension reduces specificity
stress echocardiography and perfusion
scintigraphy. If the ECG results
physical activity is positive or
cannot be interpreted
(ambiguous), then for a reliable diagnosis
myocardial ischemia requires a technique,
to visualize the appearance
ischemia, such as stress MRI of the heart,
perfusion scintigraphy or
stress echocardiography.

Definition of CHS

Continuous
relationship between blood pressure and cardiovascular
and renal events makes it difficult to choose
borderline level of blood pressure, which separated
normal blood pressure from high.
An additional difficulty is
that in the general population the distribution
SBP and DBP values ​​are unimodal
character.

Table 1

#187; Arterial hypertension #187; Risk stratification in arterial hypertension

Hypertension is a disease in which there is an increase in blood pressure, the reasons for such an increase, as well as changes, may be different.

Risk stratification in arterial hypertension is an assessment system for the probabilities of complications of the disease on the general condition of the heart and vascular system.

The general assessment system is based on a number of special indicators that affect the quality of life and its duration for the patient.

The stratification of all risks in hypertension is based on an assessment of the following factors:

• the degree of the disease (assessed during the examination);
• existing risk factors;
• diagnosing lesions, pathologies of target organs;
• clinic (this is determined individually for each patient).

All significant risks are listed in a special Risk Assessment List, which also contains recommendations for treatment and prevention of complications.

Stratification determines which risk factors can cause the development of cardiovascular diseases, the emergence of a new disorder, the death of a patient from certain cardiac causes over the next ten years. Risk assessment is performed only after the end of the general examination of the patient. All risks are divided into the following groups:

• up to 15% #8212; low level;
• from 15% to 20% #8212; the level of risks is medium;
• 20-30% #8212; level is high;
• From 30% #8212; the risk is very high.

A variety of data can affect the prognosis, and for each patient they will be different. Factors contributing to the development of arterial hypertension and influencing the prognosis may be as follows:

• obesity, violation of body weight in the direction of increase;
• bad habits (most often it is smoking, abuse of caffeinated products, alcohol), sedentary lifestyle, malnutrition;
• changes in cholesterol levels;
• tolerance is broken (to carbohydrates);
• microalbuminuria (only in diabetes);
• the value of fibrinogen is increased;
• there is a high risk by ethnic, socio-economic groups;
• the region is characterized by an increased incidence of hypertension, diseases, pathologies of the heart and blood vessels.

All risks that affect the prognosis in hypertension, according to WHO recommendations from 1999, can be divided into the following groups:

• BP rises to 1-3 degrees;
• age: women - from 65 years old, men - from 55 years old;
• bad habits (alcohol abuse, smoking);
• diabetes;
• a history of pathologies of the heart, blood vessels;
• serum cholesterol rises from 6.5 mmol per liter.

When assessing risks, attention should be paid to damage, disruption of target organs. These are diseases such as narrowing of the retinal arteries, common signs of the appearance of atherosclerotic plaques, a greatly increased plasma creatinine value, proteinuria, and hypertrophy of the left ventricular region.

Attention should be paid to the presence of clinical complications, including cerebrovascular (this is a transient attack, as well as hemorrhagic / ischemic stroke), various heart diseases (including insufficiency, angina pectoris, heart attacks), kidney disease (including insufficiency, nephropathy), vascular pathologies (peripheral arteries, a disorder such as aneurysm dissection). Among the common risk factors, it is necessary to note the advanced form of retinopathy in the form of papilloedema, exudates, hemorrhages.

All these factors are determined by the observing specialist, who conducts a general risk assessment and predicts the course of the disease for the next ten years.

Hypertension is a polyetiological disease, in other words, a combination of many risk factors leads to the development of the disease. therefore, the probability of occurrence of GB is determined by a combination of these factors, the intensity of their action, and so on.

But as such, the occurrence of hypertension, especially if we talk about asymptomatic forms. is not of great practical importance, since a person can live for a long time without experiencing any difficulties and not even knowing that he suffers from this disease.

The danger of pathology and, accordingly, the medical significance of the disease lies in the development of cardiovascular complications.

Previously, it was believed that the probability of cardiovascular complications in HD is determined solely by the level of blood pressure. And the higher the pressure, the greater the risk of complications.

To date, it has been established that, as such, the risk of developing complications is determined not only by blood pressure figures, but also by many other factors, in particular, it depends on the involvement of other organs and systems in the pathological process, as well as the presence of associated clinical conditions.

In this regard, all patients suffering from essential hypertension are usually divided into 4 groups, each of which has its own level of risk of developing cardiovascular complications.

1. Low risk. Men and women who are under 55 years of age, who have arterial hypertension of the 1st degree and do not have other diseases of the cardiovascular system, have a low risk of developing cardiovascular complications, which does not exceed 15%.

2. Average level.

This group includes patients who have risk factors for the development of complications, in particular, high blood pressure, high blood cholesterol, impaired glucose tolerance, age over 55 years for men and 65 years for women, family history of hypertension. At the same time, target organ damage and associated diseases are not observed. The risk of developing cardiovascular complications is 15-20%.

4. Very high risk group. This risk group includes patients who have associated diseases, in particular coronary heart disease, have had a myocardial infarction, have a history of acute cerebrovascular accident, suffer from heart or kidney failure, as well as people who have a combination of hypertension and diabetes mellitus.

Note:* – presence of criteria 1 and 2
required in all cases. (National
clinical guidelines VNOK, 2010).

1. Characteristic HF symptoms or complaints
sick.

2. Physical examination findings
(inspection, palpation, auscultation) or
Clinical signs.

3. Data of objective (instrumental)
examination methods (Table 2).

Significance of symptoms

VNOK recommendations, 2010.

Diagnostic criteria for the chronic phase of CML.

Hypertensive
stage II disease. Degree - 3. Dyslipidemia.
Left ventricular hypertrophy. Risk 3
(tall).

Hypertensive
stage III disease. ischemic heart disease. angina pectoris
voltage II functional class.
Risk 4 (very high).

Hypertensive
stage II disease. aortic atherosclerosis,
carotid arteries, Risk 3 (high).

- Combined or isolated increase
size of the spleen and/or liver.

- Shift in the leukocyte formula to the left
with the total number of myeloblasts and
promyelocytes more than 4%.

— Total number of blasts and promyelocytes
in the bone marrow more than 8%.

— In sternal punctate: bone marrow
rich in cellular elements
myelo- and megakaryocytes. red sprout
narrowed, white expanded. Ratio
leuko/erythro reaches 10:1, 20:1 or more in
due to an increase in granulocytes.
The number of basophils is usually increased
and eosinophils.

- size of the spleen ≥ 5 cm from under the edge
costal arch;

- the percentage of blast cells in the blood ≥ 3%
and/or bone marrow ≥ 5%;

— hemoglobin level ≤ 100 g/l;

- the percentage of eosinophils in the blood ≥ 4%.

Therapy resistant increase
the number of leukocytes;

Refractory anemia or thrombocytopenia
(amp)lt; 100×109/l, not related to therapy;

Slow but steady increase
spleen during therapy (more than
than 10 cm);

Detection of additional chromosomes
anomalies (trisomy 8 pairs, isochromosome
17, additional Ph chromosome);

The number of basophils in the blood ≥ 20%;

Presence in peripheral blood, bone
brain blast cells up to 10-29%;

The sum of blasts and promyelocytes ≥ 30% in
peripheral blood and/or bone
brain.

The diagnosis of blast crisis is established
present in peripheral blood or
more blast cells in the bone marrow
30% or when extramedullary
foci of hematopoiesis (except the liver and
spleen).

Classification of chronic lymphocytic leukemia
(CLL): initial stage, extended
stage, terminal stage.

Forms of the disease: rapidly progressive,
"frozen"

Classification of stages according to K. Rai.

0 - lymphocytosis: more than 15 X
109/l in blood, more than 40% in bone
brain. (Life expectancy as in
populations);

I - lymphocytosis increase in lymph
nodes (life expectancy 9 years);

II - lymphocytosis enlargement of the liver and / or
spleen regardless of enlargement
lymph nodes (l/y) (duration
life 6 years);

III - lymphocytosis anemia (hemoglobin
(amp)lt; 110 g / l) regardless of the increase in l / y and
organs (life expectancy 1.5
of the year).

IV - lymphocytosis thrombocytopenia less
100 X 109/l,
regardless of the presence of anemia, increased
l / y and organs. (median survival 1.5
of the year).

Classification of stages according to J.
Binet.

Stage A - the content of Hb is more than 100 g / l, platelets are more than 100 x 109 / l,
enlargement of lymph nodes in 1-2
areas (life expectancy as
in the population).

Stage B - Hb more than 100 g / l,
platelets more than 100x109/l, increase
lymph nodes in 3 or more areas
(median survival 7 years).

Stage C - Hb less than 100 g / l,
platelets less than 100x109/l at any
the number of zones with increased
lymph nodes and regardless of
organ enlargement (median survival
2 years).

Criteria for the diagnosis of CLL.

Absolute lymphocytosis in the blood more than 5
x 109/l. Sternal puncture is not
less than 30% of lymphocytes in bone punctate
brain (diagnosis verification method).

Immunological confirmation of the presence
clonal B-cell character
lymphocytes.

Enlargement of the spleen and liver
optional attribute.

Auxiliary diagnostic feature
lymphatic tumor proliferation
- Botkin-Gumprecht cells in a blood smear
(leukolysis cells are
artifact: they are not in liquid blood, they
formed during the cooking process.
smear)

Immunophenotyping, tumor
cells in CLL: CD– 5.19,
23.

Trepanobiopsy (diffuse lymphatic
hyperplasia) and flowcytometry (definition
protein ZAP-70) allow
identify B-cell infiltration and
perform a differential diagnosis
with lymphomas.

1. Chronic myeloid leukemia, phase
acceleration.

2. Chronic lymphocytic leukemia, typical
clinical option. High risk: IIIst. by K.Rai,
stage C by J.Binet.

Note. PEF - peak expiratory flow, FEV1 - forced expiratory volume for the first
second (GINA, 2007).

Bronchial asthma, mixed
(allergic, infectious-dependent)
form, moderate severity, stage IV, exacerbation, DNIIst.

- the presence of symptoms of the disease,
leading to pulmonary

hypertension;

- anamnestic indications of chronic
bronchopulmonary

pathology;

- diffuse warm cyanosis;

- shortness of breath without orthopnea;

hypertrophy of the right ventricle and right
atria on ECG: may appear
signs of overload of the right departments
of the heart (deviation of the axis of the QRS complex more than 90 degrees, an increase in the size
P wave in II, III standard leads more than 2 mm, P - "pulmonale" in II, III and aVF,
decrease in the amplitude of the T wave in standard
and left chest leads, signs
LVMH.

With constant PH, the most reliable
The signs of HMF are the following:
high or predominant RvV1, V3;
offset ST below contour
in V1, V2;
the appearance of Q in V1, V2, as a sign
right ventricular overload or
dilations; shift of the transition zone to the left
to V4, V6;
right QRS widening
chest leads, signs of complete
or incomplete blockade of the right bundle leg
Gisa.

- absence of atrial fibrillation;

- no signs of overload of the left
atrium;

- X-ray confirmation
bronchopulmonary pathology, bulging
arches of the pulmonary artery, enlargement of the right
departments of the heart;

1. HMF (thickness of its anterior wall
exceeds 0.5 cm.),

2. Dilatation of the right heart
departments of the heart (KDR of the pancreas more than 2.5 cm.),

3. Paradoxical movement of the interventricular
septum in diastole towards the left
departments,

4. Increased tricuspid regurgitation,

5. Increased pressure in the pulmonary artery.

Doppler echocardiography allows you to accurately measure
pressure in the pulmonary artery (normal
pressure in the pulmonary artery up to 20
mmHg.)

COPD: severe, stage III, exacerbation. Emphysema of the lungs.
HLS, stage of decompensation. DNIIst. HSIIIA (IIIFC according to NYHA).

Note. National clinical
VNOK recommendations, 2010.

Stages of CHF and functional classes of CHF,
may be different.

(example: CHF IIA st., IIFC; CHF IIIst., IVFC.)

coronary artery disease: stable exertional angina,
IIIFC. XSIIIA, IIIFK.

ionizing
radiation, high frequency currents, vibration,
hot air, artificial lighting;
medicinal (non-steroidal
anti-inflammatory drugs,
anticonvulsants, etc.) or
toxic agents (benzene and its
derivatives), as well as associated
with viruses (hepatitis, parvoviruses,
immune deficiency virus, virus
Epstein-Barr, cytomegalovirus) or
clonal hematopoietic diseases
(leukemia, malignant lymphoproliferation,
paroxysmal nocturnal hemoglobinuria)
as well as secondary aplasia that developed
on the background of solid tumors, autoimmune
processes (systemic lupus erythematosus,
eosinophilic fasciitis, etc.).

- three-pronged cytopenia: anemia,
granulocytopenia, thrombocytopenia;

- decrease in bone marrow cellularity
and absence of megakaryocytes according to
bone marrow punctate;

—
bone marrow aplasia on biopsy
ilium (predominance
fatty bone marrow).

Diagnosis
AA is set
only after histological examination
bone marrow (trepanobiopsy).

(Mikhailova
E.A., Ustinova E.N., Klyasova G.A., 2008).

Non-severe AA: granulocytopenia
(amp) gt; 0.5x109.

heavy
AA: cells
neutrophil series (amp)lt; 0.5x109 / l;

platelets
(amp)lt;20х109/l;

reticulocytes (amp)lt;1.0%.

Highly
severe AA: granulocytopenia:
less than 0.2x109/l;

thrombocytopenia
less than 20x109/l.

Criteria for complete remission:

hemoglobin (amp)gt;100 g/l;

granulocytes (amp)gt; 1.5x10 9 /l;

platelets (amp) gt; 100.0x10 9 /l;

no need for replacement
therapy with blood components.

1) hemoglobin (amp) gt; 80 g/l;

2) granulocytes (amp)gt; 1.0x109/l;

3) platelets (amp) gt; 20x109/l;

4) disappearance or significant
reduced dependence on transfusions
blood components.

Idiopathic aplastic anemia,
heavy form.

(after Truelove and Witts, 1955)

Nonspecific ulcerative colitis,
recurrent form, total variant,
heavy flow.

Classification of the severity of asthma according to clinical signs before treatment.

spicy
pericarditis (less
6 weeks):
fibrinous or dry and exudative;

chronic
pericarditis (over
3 months):
exudative and constrictive.

heavy
CAP is a special form of the disease
of various etiologies, manifested
severe respiratory failure
and/or signs of severe sepsis or
septic shock characterized by
poor prognosis and requiring
intensive care (Table 1).

Table 1

Complications
VP.

a) pleural effusion;

b) pleural empyema;

c) destruction / abscess formation
lung tissue;

d) acute respiratory
distress syndrome;

e) acute respiratory
failure;

e) septic shock;

g) secondary
bacteremia, sepsis, hematogenous focus
dropouts;

h) pericarditis,
myocarditis;

i) jade, etc.

Community-acquired polysegmental pneumonia
with localization in the lower lobe of the right
lung and lower lobe of the left lung,
heavy form. Right-sided exudative
pleurisy. DN II.

Sick,
suffering from GB, complain of headaches
pain, tinnitus, dizziness,
- a veil "before the eyes with an increase
AD, often pain in the heart.

Pain in the area
hearts:

angina during
all its varieties.

Pain that appears
during rises in blood pressure (they may have
both anginal and nonanginal
nature).

"Postdiuretic"
pain usually occurs after 12-24 hours.
after profuse diuresis, more often in women.
Aching or burning, lasting from
one to 2-3 days, these pains are felt
on the background of muscle weakness.

Another option
"pharmacological" pain associated with
prolonged use
sympatholytic agents.

Cardiac disorders
rhythm, especially tachyarrhythmia, often
accompanied by pain.

Pain neurotic
character /cardialgia/; by no means always
"privilege" of persons with a border
arterial hypertension. It's lengthy
aching or aching pains with spread
under the left shoulder blade, in the left hand with
numbness of the fingers.

Violations
heart rate
rare in patients with GB. Even with malignant
arterial hypertension extrasystole
and atrial fibrillation - not so frequent
finds. Since many patients with GB
have been taking diuretics for years and months,
some of them cause extrasystoles
and atrial fibrillation occurs
deficiency of K ions
and metabolic alkalosis.

Objectively:
filling of the pulse on the radial arteries
the same and quite satisfactory.
In rare cases, pulsus is determined
differens.
This is usually the result of incomplete occlusion.
large artery at its origin
from the aortic arch. For severe deficiency
myocardium in GB is characterized by alternating
pulse.

Important in
diagnostic data can be
obtained by examining the aorta and
arteries of the neck. Normal at
people of average physical development
aortic diameter in X-ray
image is 2.4 cm, in persons with
fixed hypertension
increases to 3.4-4.2 cm.

Enlargement of the heart
when GB occurs in a certain
sequences. First to the process
"outflow pathways" of the left
ventricle. Develops concentric
hypertrophy typical of long-term
isometric loads. With hypertrophy
and dilatation of "inflow tracts" left
the ventricle enlarges posteriorly, constricting
retrocardial space.

Auscultation
heart and blood vessels. Decreases
volume of 1 tone at the top of the heart.
Frequent finding - 1U / atrial / tone -
50% of patients, in II-III
stage GB. SH / ventricular tone / occurs
in about 1/3 of patients. systolic
emission noise in II
intercostal space on the right and at the apex of the heart.
Accent II
tone on the aorta. sympathetic musical
shade II
tones are evidence of duration and
severity of hypertension.

There are 5 main
types of ECG in GB.

K I
type of hypertensive
curve" we refer to ECG with high-amplitude,
symmetrical T waves in the left chest
leads.

II
type of ECG
observe in patients with established
isometric hyperfunction of the left
ventricle. On the ECG, an increase in amplitude
in the left chest leads, flattened,
two-phase 
or shallow, unequal tooth
T in lead AVL,
syndrome Tv1(amp)gt; Tv6,
sometimes deformation and broadening of the R wave.

III
ECG type
occurs in patients with an increase in
muscle mass of the left ventricle
his hypertrophy still has
concentric character. . On the ECG
an increase in the amplitude of the QRS complex
with the deviation of its total vector
backwards and to the left, flattening or biphasic

T waves in lead I
avl,
V5-6,
sometimes combined with slight displacement
ST segment
down.

IV
ECG type
characteristic of patients with advanced
clinic and more severe GB.
In addition to high-amplitude complexes
QRS
one can observe an increase
longer than 0.10 sec, and
extension of the internal deflection time
in leads V5-6
more than 0.05s. The transition zone is shifting towards
right chest lead.

V
ECG type
reflects the presence of cardiosclerosis, etc.
complications of GB. Amplitude reduction
QRS complex, traces of transferred
heart attacks, intraventricular blockades.

If hypertensive
illness for more than 2 years, moderate
hyperproteinemia and hyperlipidemia.

II. Etiological.

1. Infectious pericarditis:

viral (Coxsackie virus A9 and B1-4,
cytomegalovirus, adenovirus, virus
influenza, mumps, ECHO virus, HIV)

bacterial (staphylococcus, pneumococcus,
meningococcus, streptococcus, salmonella,
mycobacterium tuberculosis, corynobacteria)

fungal (candidiasis, blastomycosis,
coccidioidomycosis)

other
infections (rickettsia, chlamydia,
toxoplasmosis, mycoplasmosis, actinomycosis)

2.
Ionizing radiation and massive
radiation therapy

3.
Malignant tumors (metastatic
lesions, less often primary
tumors)

4.
diffuse
connective tissue diseases (RA,
SLE, periarteritis nodosa, syndrome
Reiter)

5. Systemic blood diseases
(hemoblastosis)

6. Pericarditis in diseases
with severe metabolic disorder
(gout, amyloidosis,
CKD with uremia, severe hypothyroidism,
diabetic ketoacidosis)

7.
Autoimmune processes (acute
rheumatic fever syndrome
Dressler after myocardial infarction and
open heart surgery, autoreactive
pericarditis)

8.
Allergic diseases (serum
disease, drug allergy)

9.
Side effects of some drugs
agents (procainamide, hydralazine,
heparin, indirect anticoagulants,
minoxidil, etc.)

10.
Traumatic causes (thoracic trauma)
cells, surgery
chest cavity, sounding of the heart,
rupture of the esophagus)

12. Idiopathic pericarditis

Tuberculous constrictive pericarditis
etiology. CHF IIA Art., IIFC.

Chapter VI. Gastroenterology peptic ulcer of the stomach and duodenum.

Classification of anemia by color
indicator is presented in table 1.

Table 1

Classification.

generally accepted
classification of peptic ulcer
exist. From the point
nosological independence
distinguish between peptic ulcer and
symptomatic gastroduodenal
ulcers, as well as peptic ulcer disease,
associated and non-associated
with Helicobacter pylori.

- gastric ulcers that occur within
gastropathy induced by the intake
non-steroidal anti-inflammatory
drugs (NSAIDs);

- ulcers
duodenum;

- combined ulcers of the stomach and duodenum
intestines.

- exacerbation;

- scarring;

- remission;

- cicatricial and ulcerative deformity of the stomach
and duodenum.

- solitary ulcers;

- Multiple ulcers.

- small ulcers (up to 0.5 cm);

- medium (0.6 - 2.0 cm);

- large (2.0 - 3.0 cm);

- giant (more than 3.0 cm).

- acute (for the first time identified ulcerative
disease);

- rare - 1 time in 2 - 3 years;

- frequent - 2 times a year or more.

bleeding; penetration;
perforation; development of perivisceritis;
formation of cicatricial-ulcerative stenosis
gatekeeper ulcer malignancy.

Ulcerative
ulcer disease
(1.0 cm) in the duodenal bulb
intestines, chronic course, exacerbation.
Cicatricial and ulcerative deformity of the bulb
duodenum, I
Art.

Normal values ​​of laboratory parameters Peripheral blood parameters

Classification of anemia by degree
gravity:

mild degree: Hb 110 - 90 g / l

moderate: Hb 89 - 70 g/l

severe: Hb below 70 g/l

The main laboratory signs
IDA are:

low color index;

hypochromia of erythrocytes;

increase in total iron binding
serum ability, decreased levels
transferrin.

chronic iron deficiency anemia,
medium severity. fibromyoma
uterus. Meno- and metrorrhagia.

Carotid arteries.

ultrasonic
examination of the carotid arteries with measurement
thickness of the intima-media complex (IMC) and
assessment of the presence of plaques allows
predict both stroke and heart attack
myocardium, regardless of traditional
cardiovascular risk factors.
This is true for both the CMM thickness value
at the level of the bifurcation of the carotid artery
(reflecting mainly atherosclerosis),
and for the value of KIM at the level of the general
carotid artery (which reflects mainly
vascular hypertrophy).

Pulse wave speed.

Determined that
the phenomenon of stiffness of large arteries and
pulse wave reflections are
the most important pathophysiological
determinants of ISAH and increase
pulse pressure during aging.
Carotid-femoral pulse rate
waves (SPW) is the “gold standard”
measurement of aortic stiffness.

AT
recently issued conciliation
statement, this threshold was
corrected to 10 m/s, taking into account
direct distance from sleepy
to the femoral arteries and taking into
attention 20% shorter true
the anatomical distance
a pressure wave passes (i.e., 0.8 x 12 m/s
or 10 m/s).

Ankle-brachial index.

Ankle-shoulder
index (ABI) can be measured either
automatically, with the help of devices, or
using a dopplerometer with continuous
wave and sphygmomanometer to measure
HELL. A low ABI ((amp)lt;0.9) indicates a lesion
peripheral arteries and expressed
atherosclerosis in general is a predictor
cardiovascular events and associated
approximately double the magnification
cardiovascular mortality and frequency
major coronary events compared
with total scores in each
Framingham risk category.

Table 8

Arterial hypertension in combination with chronic heart failure.

AT
as initial therapy for hypertension should
be recommended ACE inhibitors, BAB, diuretics
and aldosterone receptor blockers.
In the SOLVD study
and CONSENSUS
proven ability
increase original enalapril
survival of patients with LV dysfunction
and CHF. Only in case of insufficient
antihypertensive effect may be
calcium antagonists (CA) were prescribed
dihydropyridine series. Non-dihydropyridine
AK are not used due to the possibility
deterioration in contractility
myocardium and increased symptoms of CHF.

With asymptomatic
disease course and LV dysfunction
recommended ACE inhibitors and BAB.

AG
with kidney damage. AG is decisive
any factor in the progression of CKD
etiology; adequate BP control
slows down its development. Special attention
should be given nephroprotection when
diabetic nephropathy. Necessary
achieve tight control of blood pressure (amp)lt;
130/80 mmHg and reduce proteinuria
or albinuria to values ​​close to
normal.

To reduce
proteinuria are the drugs of choice
ACE inhibitor or ARB.

For
achievement of the target level of blood pressure with
commonly used in kidney disease
combination therapy with
diuretic (in violation of nitrogen excretion
kidney function - loop diuretic), and
Also AK.

At
patients with kidney damage, taking into account
increased risk of developing CVD often
complex therapy is indicated -
antihypertensive drugs, statins,
antiplatelet agents, etc.

Cockcroft-Gault Formula

CF = [(140-age) x
body weight (kg) x 0.85 (for women
)]

____________________________________________

[ 814* × creatinine
serum (mmol/l)].

* - When measuring the level
blood creatinine in mg/dl in this formula
instead of the coefficient 814 is used
72.

table 2

Ag and pregnancy.

SBP ≥140 mmHg and DBP ≥90 mmHg.
Elevated blood pressure needs to be confirmed
at least two dimensions. Measurement
should be done on both hands.
Pressure on right and left arms
rule is different. Should choose
the hand with the higher value
blood pressure and then
to measure arterial
pressure on that arm.

Meaning of SBP
determined by the first of two
successive tones. In the presence of
auscultatory failure may occur
underestimation of blood pressure figures.
DBP value is determined by Y
phase of Korotkoff tones, it is more accurate
corresponds to intra-arterial
pressure. Difference between DBP for IY
and Y
phase may be clinically significant.

Also, do not round
received digits up to 0 or 5, measurement
should be made up to 2 mm Hg. Art., for
what needs to be slowly bled
air from the cuff. Measurement at
pregnant women must be made in
sitting position. Lying down
compression of the inferior vena cava
distort blood pressure figures.

Distinguish
3 types of hypertension in pregnancy
differential diagnosis is not always
simple, but necessary to determine
treatment strategies and risk levels for
pregnant woman and fetus.

table 2

Prevalence
various types of arterial hypertension
in pregnant women

Term
"chronic essential hypertension"
should apply to those
women who had high blood pressure
registered before 20 weeks,
with secondary causes of hypertension excluded.

Arterial
hypertension that developed between 20
weeks of pregnancy up to 6 weeks after
childbirth, is considered directly
caused by pregnancy and
found in about 12% of women.

Preeclampsia
called a combination of arterial
hypertension and proteinuria, for the first time
detected after 20 weeks of pregnancy.
However, it must be remembered that this pathological
the process can proceed without proteinuria,
but with other symptoms (lesion
nervous system, liver, hemolysis, etc.).

The concept of "gestational hypertension"
refers to an isolated rise
BP in the second half of pregnancy.
Diagnosis can only be made
retrospectively after
pregnancy can be resolved, and
symptoms such as proteinuria, and
as well as other violations, not found
will. Compared to chronic
arterial hypertension and preeclampsia,
prognosis for woman and fetus
gestational hypertension most
favorable.

AT
first two trimesters of pregnancy
all are contraindicated
antihypertensive drugs other than
methyldopa. In the third trimester of pregnancy
possible use of cardioselective
BAB. SBP (amp)gt;170 DBP (amp)gt;119 mmHg pregnant
women is regarded as a crisis and is
indication for hospitalization. For
intravenous therapy should be used
labetalol, for oral administration - methyldopa
or nifedipine.

Strictly
ACE inhibitors and ARBs are contraindicated
due to the possible development of congenital
malformations and fetal death.

Multiple myeloma.

Clinico-anatomical
classification
based on x-ray data
skeletal and morphological studies
analysis of punctates and trepanates of bones,
MRI and CT data. Allocate diffuse-focal
form, diffuse, multiple-focal,
and rare forms (sclerosing),
predominantly visceral). stages
multiple myeloma (MM) are presented
in the table.

Refractory ag.

Refractory
or treatment-resistant are considered
hypertension in which the prescribed treatment is
lifestyle change and rational
combined antihypertensive
therapy with adequate doses
at least three drugs, including
diuretics, does not lead to sufficient
lower blood pressure and achieve its target
level.

In such cases, detailed
examination of OM because with refractory
AH in them are often observed pronounced
changes. it is necessary to exclude secondary
forms of hypertension that cause
refractory to antihypertensive
treatment. Inappropriate doses of antihypertensives
drugs and their irrational combinations
may result in inadequate reduction
HELL.

Main
causes of treatment-refractory hypertension
are presented in table 3.

Table
3.

Causes of refractory
arterial hypertension

Emergency conditions

All
situations that are to some extent
dictate a rapid decrease in blood pressure, subdivide
into 2 large groups.

states,
requiring emergency treatment - reduced
BP during the first minutes and hours of
help of parenteral drugs.

urgent
therapy is necessary with such an increase
BP, which leads to the appearance or
exacerbation of symptoms from OM:
unstable angina, myocardial infarction, acute
LV insufficiency dissecting
aortic aneurysm, eclampsia, MI, edema
optic nerve papilla. Immediate
decrease in blood pressure is indicated in CNS trauma, in
postoperative patients, with a threat
bleeding, etc.

Vasodilators

Nitroprusside
sodium (may increase intracranial
pressure);

Nitroglycerine
(preferred for myocardial ischemia);

• 
  (preferable in the presence of CHF)

Antiadrenergic
facilities
(phentolamine for suspected
pheochromocytoma).

Diuretics
(furosemide).

Ganglioblockers
(pentamine)

Antipsychotics
(droperidol)

HELL
must be reduced by 25% in the first 2 hours
and up to 160/100 mm Hg. over the next
2-6 hours. Don't lower your blood pressure too much
quickly to avoid ischemia of the central nervous system, kidneys
and myocardium. With blood pressure (amp) gt; 180/120 mm Hg. his
should be measured every 15-30 minutes.

states,
requiring a decrease in blood pressure for several
hours. Samo
by itself, a sharp increase in blood pressure, not
accompanied by symptoms
from other organs, dictates
mandatory but not so urgent
intervention and can be stopped
oral medication with
relatively fast acting: BAB,
AA (nifedipine), clonidine, short acting
ACE inhibitors (captopril), loop diuretics,
prazosin.

Treatment
patient with uncomplicated GC
carried out on an outpatient basis.

To
the number of states requiring relatively
urgent intervention,
malignant
AG.

At
malignant hypertension is observed extremely
high blood pressure (DBP (amp) gt; 120 mm Hg) with the development
pronounced changes in
vascular wall, leading to ischemia
tissue and organ dysfunction. AT
development of malignant hypertension
participation of many hormonal systems,
activation of their activity causes
increased natriuresis, hypovolemia, and
also damages the endothelium and proliferates
MMC intima.

Syndrome
malignant hypertension is usually accompanied by
progression of CKD, worsening
vision, weight loss, symptoms of
CNS, changes in rheological properties
blood up to the development of DIC,
hemolytic anemia.

Patients
with malignant hypertension, treatment is indicated
a combination of three or more antihypertensive
drugs.

At
treatment of severe hypertension should be aware of
the possibility of excess excretion from
body sodium, with intensive
the appointment of diuretics, which is accompanied
further activation of the RAAS and an increase
HELL.

Sick
with malignant hypertension should be more
once carefully examined for
the presence of secondary hypertension.

CKD risk factors.

History of kidney damage;

Polyuria with nocturia;

Reducing the size of the kidneys
according to ultrasound or x-ray
research;

Azotemia;

Relative density reduction and
urine osmolarity;

Decreased GFR (less than 15 ml/min);

Normochromic anemia;

Hyperkalemia;

Hyperphosphatemia combined with
hypocalcemia.

Criteria for diagnosis.

a)
acute fever at the onset of the disease
(to(amp)gt; 38.0°C);

b) cough with sputum;

in)
objective signs (shortening
percussion sound, crepitus focus
and/or fine bubbling rales, hard
bronchial breathing);

G)
leukocytosis (amp)gt; 10х109/l
and/or stab shift ((amp)gt; 10%).

Absence
or unavailability of X-ray
confirmation of focal infiltration
in the lungs (X-ray or large-frame
chest x-ray)
makes the diagnosis of CAP inaccurate/uncertain.
The diagnosis of the disease is based on
based on epidemiological data
anamnesis, complaints and relevant
local symptoms.

under the term " arterial hypertension", "arterial hypertension"is understood as the syndrome of increased blood pressure (BP) in hypertension and symptomatic arterial hypertension.

It should be emphasized that the semantic difference in terms " hypertension" and " hypertension"practically none. As follows from the etymology, hyper - from Greek over, over - a prefix indicating excess of the norm; tensio - from Latin. - stress; tonos - from Greek. - stress. Thus, the terms "hypertension" and " "hypertension" essentially means the same thing - "overstress".

Historically (since the time of G.F. Lang), it has developed so that in Russia the term "hypertension" and, accordingly, "arterial hypertension" are used, in foreign literature the term " arterial hypertension".

Hypertensive disease (AH) is commonly understood as a chronic disease, the main manifestation of which is the syndrome of arterial hypertension, not associated with the presence of pathological processes, in which an increase in blood pressure (BP) is due to known, in many cases, eliminated causes ("symptomatic arterial hypertension") (Recommendations of VNOK, 2004).

Classification of arterial hypertension

I. Stages of hypertension:

• Hypertension (AH) stage I suggests the absence of changes in the "target organs".
• Hypertension (AH) stage II is established in the presence of changes from one or more "target organs".
• Hypertension (AH) stage III established in the presence of associated clinical conditions.

II. Degrees of arterial hypertension:

The degrees of arterial hypertension (Blood pressure (BP) levels) are presented in Table 1. If the values ​​of systolic Arterial pressure (BP) and diastolic Arterial pressure (BP) fall into different categories, then a higher degree of arterial hypertension (AH) is established. The most accurate degree of Arterial hypertension (AH) can be established in the case of newly diagnosed Arterial hypertension (AH) and in patients not taking antihypertensive drugs.

Table number 1. Definition and classification of blood pressure (BP) levels (mm Hg)

III. Criteria for risk stratification of patients with hypertension:

I. Risk factors:

a) Basic:
- men > 55 years old - women > 65 years old
- smoking.

b) Dyslipidemia
TC > 6.5 mmol/L (250 mg/dL)
HDLR > 4.0 mmol/L (> 155 mg/dL)
HSLPV

c) (in women

G) abdominal obesity: waist circumference > 102 cm for men or > 88 cm for women

e) C-reactive protein:
> 1 mg/dl)

e):

- Sedentary lifestyle
- Increased fibrinogen

g) Diabetes:
- Fasting blood glucose > 7 mmol/l (126 mg/dl)
- Blood glucose after a meal or 2 hours after ingestion of 75 g glucose > 11 mmol/L (198 mg/dL)

II. Target organ damage (stage 2 hypertension):

a) Left ventricular hypertrophy:
ECG: Sokolov-Lyon sign> 38 mm;
Cornell product > 2440 mm x ms;
EchoCG: LVMI > 125 g/m 2 for men and > 110 g/m 2 for women
Rg-graphy of the chest - cardio-thoracic index> 50%

b) (thickness of the intima-media layer of the carotid artery >

in)

G) microalbuminuria: 30-300 mg/day; urinary albumin/creatinine ratio > 22 mg/g (2.5 mg/mmol) for men and >

III. Associated (comorbid) clinical conditions (stage 3 hypertension)

a) Main:
- men > 55 years old - women > 65 years old
- smoking

b) Dyslipidemia:
TC > 6.5 mmol/L (> 250 mg/dL)
or CHLDL > 4.0 mmol/L (> 155 mg/dL)
or HSLVP

in) Family history of early cardiovascular disease(among women

G) abdominal obesity: waist circumference > 102 cm for men or > 88 cm for women

e) C-reactive protein:
> 1 mg/dl)

e) Additional risk factors that negatively affect the prognosis of a patient with arterial hypertension (AH):
- Impaired glucose tolerance
- Sedentary lifestyle
- Increased fibrinogen

g) Left ventricular hypertrophy
ECG: Sokolov-Lyon sign> 38 mm;
Cornell product > 2440 mm x ms;
EchoCG: LVMI > 125 g/m 2 for men and > 110 g/m 2 for women
Rg-graphy of the chest - cardio-thoracic index> 50%

h) Ultrasound signs of thickening of the artery wall(thickness of the carotid intima-media layer >0.9 mm) or atherosclerotic plaques

and) Slight increase in serum creatinine 115-133 µmol/L (1.3-1.5 mg/dL) for men or 107-124 µmol/L (1.2-1.4 mg/dL) for women

to) microalbuminuria: 30-300 mg/day; urine albumin/creatinine ratio > 22 mg/g (2.5 mg/mmol) for men and > 31 mg/g (3.5 mg/mmol) for women

l) Cerebrovascular disease:
Ischemic stroke
Hemorrhagic stroke
Transient cerebrovascular accident

m) heart disease:
myocardial infarction
angina pectoris
Coronary revascularization
Congestive heart failure

m) kidney disease:
diabetic nephropathy
Renal failure (serum creatinine > 133 µmol/L (> 5 mg/dL) for men or > 124 µmol/L (> 1.4 mg/dL) for women
Proteinuria (>300 mg/day)

about) Peripheral artery disease:
Dissecting aortic aneurysm
Symptomatic peripheral arterial disease

P) Hypertensive retinopathy:
Hemorrhages or exudates
Optic nerve edema

Table number 3. Risk stratification of patients with arterial hypertension (AH)

Abbreviations in the table below:
HP - low risk,
UR - moderate risk,
VS - high risk.

Abbreviations in the table above:
HP - low risk of arterial hypertension,
UR - moderate risk of arterial hypertension,
VS - high risk of arterial hypertension.