Clinical recommendations for arterial hypertension. Arterial hypertension Recommendations for arterial hypertension

Shanovny colleagues!
On the testimony of the participant of the seminar, as soon as a test run by you is successful, the calendar date of your on-line participation in the seminar will be indicated.

Seminar "Arterial hypertension in 2016: successful progress to the classification, diagnostics and treatment"

conduct: Republican Medical University

Carried out date:

Arterial hypertension (AH) is the factor that has modified the heart-vascular rhizicum. The link of the advanced arterial vise (AT) is recognized as the development of fatal and non-fatal myocardial infarctions and cerebral strokes, as well as with the accelerated progress of chronic diseases.

At the same time, briefly discuss happy announcement about classifications, diagnostics and diagnostics of hypertension. For a number of materials published in 2013-2014 rr. documents, including: 1) Recommendations of the European Association of Hypertension and the European Association of Cardiologists (ESH / ESC) on the basis of AG, 2013; 2) CLINIC RECOMMENDATIONS by the American Society of Hypertension AG and International Society of Hypertension (ASH / ISH), 2013); 3) Eight Recommendations of the United National Committee of the United States on the management of an advanced arterial vise in older adults (JNC-8).

Viznachennya. Terminom AG means a camp, with a good weight stike adjustment of arterial pressure: systolic arterial vise ≥ 140 mm Hg. і / abo diastolic AT ≥ 90 mm Hg. The classification of AT and AG stages is presented in Table 1.

Table 1. Classification of antibodies (mm Hg) and stages of hypertension

see pervinnu AG (Also, the term "essential AG" « hypertensive ailment» ), When the arterial vise is pushed forward, it is not tied with any kind of organ damage, i second (or "symptomatic") hypertension In the case of hypertension, it is tied with lesions of the growth organs / tissues (Table 2).

Among all the specialties of the AG, the part of patients with hypertensive ailments become close to 90%; on a part of all over-anchored in the table 2 symptomatic hypertension, the total seizure is close to 10%. Among symptomatic hypertension, the most frequent is renal (up to half of the symptoms of symptomatic hypertension).

Table 2. Classification of AG for ethology

Classification of AG behind the step of the heart-vascular rhizik

Standard at a time є visualization (and indication in the formulation of diagnoses) of the stages of pre-cardiovascular rhizicum in hypertension (Table 3); For the whole, it is accepted that the patient has an order of hypertension, as well as factors in the heart-vascular rhizic, the level of organ-targets and fellow sickness(Table 4).

Table 3. Equivalent of antecedent vascular rhizicum in hypertension

Notes: FR - factor of riziku, POM - reduction of organ-targets, SZ - supportive illness, SD - diabetics (div. Table 4). According to the Framingham criteria, the terms "low", "middle", "high" and "even high" rhizik mean 10-fold vigor development of the heart-judgment slow (deadly and non-fatal)<15%, 15-20%, 20-30% и >30%, admittedly.

Table 4. Factors of heart-vascular rhiziku, deterioration of organ-targets and supportive illness in hypertension

Notes: CS - cholesterol; LPNSCH - lipoprotein of low proficiency; LPVShch - lipoprotein high school; TG - triglyceride; EKG - electrocardiogram; LSh - livy slunk; SCF - glomerular filtration rate.

* - EKG - diagnosis of LSH hypertrophy ... index of Sokolov-Lyon: SV1 + (RV5 or RV6); Cornell's tvir in choloviks: (RavL + SV3) x QRS (ms), in women: (RavL + SV3 +8) x QRS (ms).

** –Echocardiographic diagnosis of LSH hypertrophy. For tsoh in Danish hour, the formula of the American Society of Echocardiography - ASE, in the Yakiy mass of myocardium LSh (LVMM) = 0.8 x (1.04 x (KDR LSh + TZSLZh + TMZhP) 3 - (KDR LSh) 3)) + 0.6 , De KDR LSh - kintsevo-diastolic size LSh; TZSLZH - tovshchina back wall of LSh in diastolu; TMZhP - tovshchina mіzhshlunochkovo ї partitions in diastole. For pidrakhunku index LVMM, when the formula is victorious, the value of LVMM walk on the surface of the sick person (The table indicates the normal value of the LVMM index for such a variant). Deyakіxperti vvazayut more acceptable index of MMLV is mute on the surface of the floor, but on the growth of a sick person at a level of 2.7 (growth rate 2.7) or an increase at a level of 1.7 (growth rate 1.7) - for a polydensity tila for obesity.

*** – Increased pulse rate Check out the additional mechanical and Doppler reconstruction of the pulse rate on sleepy and stegovy arteries.

**** –Logic-shoulder index - delivery of systolic arterial vise on the ankle (cuff - on distal view homilka) to systole AT on the shoulders.

There are 1 representations of the SCORE scale options per minute, recommendations by European experts using the assessment of the heart-and-heart rhizik for the regions of the cob, the highest population of such rhizik (including for Kazakhstan). For the correct correction with a scale, one should know the cliché, based on these indicators of statis, vik, systolic arterial grip and zahalal cholesterol, as there is a specific patient. The number assigned in the class will represent the approximate value of the 10th risk of death due to heart-and-vascular causes (circulated in all). According to the SCORE scale, there is an onset of the 10-category risk of death from cardiovascular causes: even high (≥ 10%), high (5-9%), low (1-4%) and low (0%).

Malunok 1. Riziku Scale (SCORE - Systematic COronary Risk Evaluation), as estimated 10-day risk of death from heart-and-heart disease in fallowness from stati, vіku, kurinnya, arterial vise and zahalal cholesterol of blood (options recommended by ESC experts for the country, which may be a high level of heart disease in the population for Kazakhstan), including populations that do not have heart disease and diabetic diabetes, for patients ≥ 40 years *

Notes: Cholesterol - gallant cholesterol; * - є larger folding options of the scale, de vrahoyutsya і equal HC LPNSH and HS LPVShch; All scale options and electronic calculators are available online - see www.escardio.org

Epidemiology

AG is one of the most advanced chronic ailments. AG - the most chronic illness in the practice of the doctor of the primordial lanka nadannya medical aid(The doctor of the foreign practice - the family doctor). AH MA MISCE Approximately one third of the population of the most developed regions is developing. When analyzing the structure of AG behind the level of AT, approximately 1/2 maє mice AG has 1 step, 1/3 - 2 steps, and 1/6 - 3 steps. The breadth of the AG is increasing in size; not less than 60% of individuals in patients> 60-65 years of arterial grip may be affected or antihypertensive therapy can be accepted. In the middle of the 55-65 year period, the growth rate of the AG, according to the tribute of the Fremingemskogo doslidzhennya, becomes 90%.

All-day organization of health protection AG yak most important for potentially preventing causes of death in the world .

AG assists in the improvement of the heart-vascular mortality and the reduction in the heart-vascular acceleration in all groups; In the middle of the steps of the rhizik, there is a straight link with the level of the systolic arterial vise (SAT) and the ring with the level of the diastolic AT (DAT).

Є There is also a neat connection between the AH manifestation, from one side, and the development of heart failure, a decrease in peripheral arteries and a decrease in the function of the lower one, from the lower side.

For epidemiological data, in the provinces Approximately 50% of people with hypertension do not know about the presence of an increased arterial grip (Tobto diagnosis of AH they have not been established); In the middle of the AH, it is close to 10% control of the arterial grip in the inter-range digits.

Isolated systolic hypertension (ICAG) in patients

The commission of the expert examiners is to look out like a pathological camp, in power to the people of the kidnapped, tied to changes in the flexibility of the arteries; with ISAG, GARDEN is increased and DAP is decreased (Table 1). GARDEN ADVISION is an important pathophysiological official, for the development of hypertrophy of the heart; A decrease in DAP can be produced to a decrease in coronary blood flow. Expansion of ISAG is increasing in succession; in lіtnіkh osіb tse - the most common form of hypertension (Up to 80-90% of all types of hypertension).

Have lіtnіkh osіb The manifestation of ISAG is not tied with larger significant increases in the step of the heart-vascular rhizik , There is no evidence of systolic-diastolic hypertension (with the relative values ​​of SBP).

For the assessment of the level of pre-cardiovascular rhizic in case of ISAH, it is necessary to show the same level of systolic blood pressure, as well as to determine the factors of rhizic, the defeat of organ-targets and supportive diseases, and in the case of systolo-dystol. With a lot of mothers on uvaz, scho especially low RVNI DAT (60-70 mm Hg and lower) associated with additional adjustments .

"AG white dressing gown"

It is diagnosed, if AT, in the cabin of the car, become ≥140 / 90 mm Hg. not less than in 3 cases, with normal values ​​of AT, there is a booth for the data of outpatient monitoring of AT (AMAD - see "Diagnostics of AG"). "AG of a white robe" is often seen in children of a kidnapped person. Get involved scho heart-vodinniy rizik in such patients, lower, lower in ailments with persistent hypertension (tobto with levels of AT, as it is normal with a reduced level of sleep and with AMAD), ale, ymovirno, vishche, lower in normotensive individuals. Some people are recommended to change the way of life, and in the presence of a high heart-and-heart rhizik and / or even less organ-targets - drug therapy(Div in distribution "Likuvannya AG").

diagnostics of hypertension

Rivni AT is characterized by spontaneous variability with a stretch to finish, and also with a stretch for more lengthy trips in an hour (tizhni-mіsyatsі).

Diagnosis of hypertension is guilty of being guilty based on the dues of multiple ATs , Vikonanikh under different circumstances; the standard statement of the AG is transferred for data not less than 2-3 visits to the lykar (before an hour of skin visit of AT, it was guilty that it was caused by a stretch of not less than 2 times) .

It’s just about the hour of the first visit to the driver of AT, if there’s no change Then I will re-evaluate the AT after the visit through a likely longer period - through a few months (which is the level of AT from the 1st stage of the AG - Table 1).

In times, when the hour of the first visit the AT level of advancement is larger (see the 2nd stage of the AG - Table 1) If it is possible to tie from AG to the destruction of organ-targets, or if the level of an early heart-vascular rhizik is high, then the repeated assessment of AT is guilty of being broken through an altogether longer () interval of an hour; how much is the level of arterial vise before the hour of the first visit to the 3rd stage of the AG , Yaksho є the symptomatology of hypertension, the level of pre-cardiovascular rhizicum is high, then the diagnosis of hypertension can be based on the dannyh, when one goes to the drug.

Vimіryuvannya arterial vise

It is standardly recommended to use an arterial vise mercury sphіgmomanometer or anerous manometer (They left a significant extension in the connection with the tendency to the decline of mercury from a wide victorian). Independently in sight, the device for the arterial grip of guilt reference , Їх indicators of guilt are periodically recirculated (when presented with the data of the other devices, mercury sphigmomanometers are used).

You can also vikorystannya napivautomatic attachments for vimіryuvannya arterial vise ; the accuracy of the robots is guilty but established according to standard protocols; It is shown that the arterial vise is guilty of being periodically reconsidered when presented with data from mercury sphigmomanometers.

Outpatient monitoring of AT ( AMAD) in accordance with the high level of control of AT. AMAD allows you to eliminate the possible inaccuracies of the patient, related to the defects of his technique, the incompatibility of the apparatus, and of the patient. The whole method also provides for the possibility of rejecting these multiple ATs in a 24-year period without adding to the patient's emotional status. Win vvazhaєtsya more vіdvorenim, nіzh epіzodichne vimіr. Dani AMAD mensh shhilny until pouring in "the effect of a white dressing gown."

Рівні АТ, re-established at AMAD, call the lower ones for those, how to appear at the same time in the cabinet of the car (Table 6, 7).

Table 6. The value of the AG for the data of the arterial vise in the cabinet of the doctor and the posture of the cabinet of the doctor

Shown for AMAD include: 1) the lack of clarity in the diagnosis of hypertension, a pretense about the appearance of the "white dressing gown effect"; 2) the need for an assessment of the status of AT for a test, especially since it is given in the cabin of a car to easily change the price of AT; 3) I mean the variability of the tributes that are taken out when the AT is in the cabin of the car; 4) a preference for the manifestation of the resistance of AH to lykuvannya; 5) a statement about the manifestation of hypotheses.

Table 7. Principles of carrying out AMAD

Monitoring of AT budinku (Maddy): changes and events (Table 8) . The whole method is becoming more and more expandable, especially with the expansion of the storage of automatic devices for the reduction of the arterial grip.

Table 8. Principles of conducting Maddy

Desecration of ailments from AG

Defending ailments from AH (including anamnesis - table 9, parts 1 and 2; on an active basis - table 10; as well as laboratory and instrumental information - table 11)

• provoke AG factors;
• hitting organs-targets;
• Danikh about the manifestation of symptomatic hypertension;
• Clinical manifestations of heart-vascular acceleration (chronic heart failure, vasodenum and peripheral vascular disease);
• adolescents (diabetics, fibrillation at the front of the heart, deterioration of cognitive function, frequent falls, cunning while walking, etc.), which can be imprinted on vibrational tactics.

Table 9. Features to take anamnesis in patients with hypertension (1 part)

Note: NPZP - non-steroidal anti-inflammatory drugs

Table 9. Features to take anamnesis in patients with hypertension (part 2)

Table 10. Features of the active diagnosis of ailments from the AG
(Poshuk symptomatic hypertension, lesion of target organs, obesity)

Table 11. Laboratory and instrumental dosage in hypertension

lykuvannya AG

Acceptable to the control of the arterial clutch in the boundaries of the central regions in individuals with hypertension (according to the data of PCI and meta-analysis).

It is shown that there is a change in the heart-vascular mortality and the frequency of the heart-vascular acceleration; It also means that the development of chronic heart failure is different from the reduction of the risk.

The decrease in the risk of strokes against the background of antihypertensive therapy was more pronounced, less the decrease in the risk of coronary acceleration. Thus, the decrease in diastolic AT for everything by 5-6 mm Hg. to reduce the risk of development of the stroke of 5 rock by approximately 40%, and the ischemic ailments of the heart - by approximately 15%.

Chim more swings the steps of the lowering of the arterial vise (in the boundaries of the tsilovyh ravniv), Tim is more friendly for the prognosis.

Pererakhovani friendly efects are also shown in individuals of a kidnapped person, incl. at mayut isolated systolic hypertension. Friendly efficiencies of different values ​​in sick children of ethnic groups (in small, black, Asian populations and in.).

Tsіlі lіkuvannya AG. The main meta lіkuvannya AG - tse a decrease in the heart-vascular rhizik, a decrease in the rhizik development of CHF and chronic nirkova lack ... Friendly efficacy of guilty but spivvidneseny with a rizik, we will tie with by quick lykuvannya. In the case of practical tactics, it is important to transfer, enter, direct on the correction of other factors that can be corrected in a sickly, potentially corrected factor in the heart-judging rhizic, including course, dislipidem, abdominal obesity.

Tsilovi pivni AT, recommended by experts from Europe and the United States in the course of antihypertensive therapy, are presented in table. 12. For the category of people with illnesses from the AG, it is important to mother in respect, since they have equal AT to be more significant than to change; that the stench is more healthy until the development of hypotheses of hypotension (including orthostatic, postural hypotensives). The vibration of the whole arterial vise for a particular patient is guilty of being individual.

Table 12. Tsilovi pivni AT for ailments AG

Note. * - at low rivnya "proof base".

non-pharmacological treatment

Pererakhovanі lower zmіni style of life with a decrease in the arterial grip and a decrease in the heart-vascular rhizik:

• Reduced weight for obese patients (Yaksho index of oil is more than 30 kg / m 2). It has been shown that in such patients, the decrease in blood volume by 1 kg leads to a decrease in systolic arterial vise by 1.5-3 mm Hg, diastolic AT - by 1-2 mm Hg.
• regular physical options on every (For a hemodynamically stable patient - not less than 150 (and more beautifully - not less than 300) quills per day; for people who are sick, they can reach 30-45 quills a day with a stretch of 30-45 quills, or not less than 5 times per day). Isometric navantazhennya (for example, pidyom vantazhiv) to move the blood grip, їkh bazhano vyklyuchiti.
• replacement vzivannya kitchen salt ... It has been shown that a decrease in the living salt up to 5.0 g / day (the style is taken in 1/2 teaspoon) is associated with a decrease in systolic arterial vise by 4-6 mm Hg, diastolic AT - by 2-3 mm Hg. Art. ... A decrease in AT due to a decrease in the implantation of a salt was more pronounced in a patient with a kidney disease. Yak to finish the second come in (when you have a decrease in the amount of salt by about 30%), you can get a recommendation from the table.
• Zmensennya implantation to alcohol.
• Changing the implantation of weed fat (Fat food stuff).
• Improving the implantation of fresh fruits and vegetables (Sumarno bazhano close to 300 g / dobu),
• prinennya kurinnya .

pharmacological treatment

Pharmacological treatment (tab. 13) required more ailments from the AG , The main meta tsyogo treatment is the improvement of the heart-vascular forecast.

Table 13. General nutritional pharmacological treatment for hypertension

Shown scho The intake of antihypertensive drugs in patients with hypertension in patients up to 80, so ≥80 times will lead to changes in heart-vascular prognosis. Adequate pharmacological treatment of hypertension does not spoil the unpleasant injecting into cognitive function in people with illnesses who do not promote the development of dementia; moreover, vono, ymovіrno, maybe such a risik znizhuvati.

Likuvannya guilty to fix it small doses , You can step by step if necessary, you can change it. Douzhe bazhaniy vibir drugіv z good triviality .

Tables 14-17 show the classes of antihypertensive drugs; mіsce sartanіv more detailed view of the distance.

Table 14. Diuretics in hypertension (adapted from ISH / ASH, 2013)

Notes: * - enter the warehouse of the fixed combination telmisartan with hydrochlorothiazide; ** - admit to antagonists of minerlocorticoid receptors (antagonists of aldosterone); # - when the function is lowered, there can be more high doses.

Table 15. Blockers of calcium channels (calcium antagonism) in hypertension (adapted from ISH / ASH, 2013)

Notes: * - enter the warehouse of the fixed combination telmisartan with amlodipin;
** - HR - heart rate is very fast.

Table 16. Angibitories of ACE in hypertension (adapted from ISH / ASH, 2013)

Table 17. β-blockers in hypertension (adapted from ISH / ASH, 2013)

Note: * - in Danish hour є read the tendencies to the speedy victorianny of atenolol in lykuvanni AG and ischemic ailments of the heart.

Misce sartan (antagonists of receptors in angiotensinII)

in lіkuvanni AG

According to the Expert Recommendations ESC / ESH - 2013, ASH / ISH - 2013 and JNC-8 - 2014, Sartan is seen as one of the main, most frequently implanted classes of antihypertensive drugs. Further in the text, as well as in Tables 18-19, the main data are presented, which should be used for the whole class of drugs, which should be suggested in our negotiated recommendations.

Table 18 shows the dosage and the multiplicity of sucking sartans in hypertension.

Table 18. Sartani in Lykuvanni AG (adapted from ISH / ASH, 2013)

The pharmacological features of sartans are presented in table 19.

Table 19. Pharmacological peculiarities of sartans (adapted from Kaplan NM, Victor RG, 2010)

Notes: * - for all sartans є fixed combinations with thiazide / thiazide-like diuretics; ** - the infusion on Peroxisome proliferator-activates the γ-receptor more strongly in telmisartan, less pronounced in Irbesartan - it does not give rise to supplemental effects on glucose and lipid metabolism.

Sartana, yak іngіbіtori ACE, against the renіnangіotensinovy ​​system. Smell to lower the arterial grip, blocking angiotensin II on the AT1 receptor, and by itself blocking the subozuzhuvulyu cych receptors.

Sartana is good to be transferred. The stench does not wick the cough; at їkh vicoristannі in the region, there is a rіdko vinikak angіoneurotic nabryak; These efects and passages are similar to those of the ACE Ingibitors. To that, as a rule, їх stasis is more beautiful, nіzh victoriannya іngіbіtorіv ACE. Yak іngіbіtory ACE, Sartana can increase the level of syrovatous creatinine up to 30%, mainly through a decrease in the grip in the glomerular glomeruli and a decrease in the fluidity of the glomerular filtration. There are changes, as a rule of thumb, reversals (transient) and not associated with pre-construction reductions in the functions of nirok (they look like they are not very long).

Sartana does not conceal the dose of late side effects, but it allows even on the cob stage of the process of vikoristovuvati average or to find the maximum hardened dose (so that it does not vimage the titration).

Sartana may also be friendly to the heart-vascular and nircovian prognosis, as well as the ingibitoria of the ACE.

Yak and іngіbіtory ACE, Sartana produce more antihypertensive (and organoprotective) effects on small and Asian patients; The mensh of bends is for chornoschkirich patients, however, when victorian sartans are in combination with being a blocker of calcium channels, or a diuretic effect of becoming an independent type of race.

One-way є recommendation not to create a combination of sartans with ACE Ingibitors; leather from cich likarsky zasobіv nadaє friendly renault-protective effects, albeit in a combination of stench can fix a negative infusion on a nirkovy prognosis.

On the cob of vicarious sartans in individuals who are also taking diuretics, you can be sure to skip taking a diuretic to prevent a sharp decrease in arterial grip.

Sartana is not guilty of stagnation in vagina, especially in 2 and 3 trimesters, a bit of stench can give rise to normal development of the fetus.

the power of telmisartan

(Including fixed combinations

with hydrochlorothiazide and amlodipin).

Telmіsartan - one of naybіlsh vivchenih i efektivnosti predstavnikіv Klas sartanіv, vіn harakterizuєtsya bearing-down i stіykim antigіpertenzivnim dієyu, nayavnіstyu complex organ-i spriyatlivih metabolіchnih efektіv, Visoko rіvnem "dokazovoї bazi" for positive vplivu on Sertsevy-sudinny, cerebrovascular i nirkovy forecast otrimanoї in naybіlshih randomized controls until recently. More detailed characteristics of telmisartan are presented in table 20.

It is necessary to pay respect to the appearance of also two versions of the fixed combination of the original telmisartan - additionally with hydrochlorothiazide (tablets of 40 / 12.5 mg and 80.12.5 mg - Table 20) and preparation of 80/5 mg 80/10 mg - Table 21). With regard to the priority mission, as a combination of antihypertensive therapy (Div. Nizche) is introduced at once, there can be seen one of the most important components of the general tactics of antihypertensive treatment.

Table 20. Zagalna characteristic telmisartan and fixed combination telmisartan with hydrochlorothiazide - 1 part

Table 20. General characteristics of telmisartan and fixed combination of telmisartan with hydrochlorothiazide - 2 parts

Table 21. Characteristics of the original fixed combination telmisartan (80 mg) and amlodipin (5 mg or 10 mg) - 1 part

Table 21. Characteristics of the original fixed combination telmisartan (80 mg) and amlodipin (5 mg or 10 mg) - 2 parts

Vibir of tactics:

monotherapy or combined antihypertensive therapy?

On babies 2 and 3 are presented to go to the choice of drug tactics in hypertension, recommended by reason, by experts from Europe, 2013 rock and USA, 2013 r

Malunok 2. Go to the choice of monotherapy or combined therapy in hypertension ESC-ESH, 2013

Malunok 3. Go to the choice of political tactics in hypertension, USA, 2013

Note: TD - thiazide diuretics; CHF - chronic heart failure; SD - diabetes diabetics; XXN - chronic illness nirok.

Bagatio we are sick at the same time on the cob stage of the treatment can be assigned combined antihypertensive therapy two drugs. For baby 4 there are presented the combination of antihypertensive drugs recommended by ESC-ESH experts in 2013. If necessary, use tri-component antihypertensive therapy (addictive - calcium channel blocker + thiazide diuretics + іngіbіtor APF/ Sartan). It is not recommended to combine the ACE Ingibitor with sartans.

In case of the presence of a sickly high or even a high level of an extra heart-vascular rhizik, it is included in the dietary strategy of guilt. statini (For example, atorvastatin in a dose of 10 mg / day, with the presence of a supportive IXC, the dose is guilty of butyce) aspirin (75-100 mg / day, when the AT control is reached, during the evenings) - with tolerance and day-to-day contraindication, for continuous use. The main meta-sign of statin and aspirin in the whole range is the reduction of the rhizicum of the heart-vascular acceleration.

Malunok 4. Combinations of antihypertensive drugs

Note: Combinations, meaning green succinct linen (letter "a" ), Є short (rational); green redistribution line (letter " b ») - also rational, ale with deyakie intercourse; black and red (letter "s") - mozhlivim, ale mensh vivchenim; chervona lininya (letter " d ») by not recommending a combination.

Visnovok. It is possible for the presented bag to show that: 1) with the choice of a political strategy among ailments from the AG, a doctor of foreign practice, family likarі cardiologist followed the presentation in the new recommendations for antihypertensive drugs; 2) in the middle of the antihypertensive class, they have earned a lot of respect (which was traditionally used by the majority of practicing clinicians). Sartan is highly effective and non-baked preparations with friendly, well-planned organoprotective effects and positive influx into the prognosis; 3) telmisartan (which is isolated, so at the sight of fixed combination with hydrochlorothiazide or amlodipine) can be seen far away by vibration antihypert low cost in bagatiokh ailments from AG .

Umovni speedy:

AH - arterial hypertension

AT - arterial vise

ACE - angiotensin-converting enzyme

BKK - blockers of calcium channels

β-AB - β-adrenergic blockers

DMAT - dobove monitoring AT

SCF - glomerular filtration rate

XXN - chronic illness nirok

LIST OF LITERATURE:

1. Sirenko Yu.M. Hypertensive ailments and arterial hypertension / Yu. M. Sirenko. - Donetsk: Vidavnichiy dim Zaslavsky, 2011 .-- 352 p.
2. AHA / ACC Guideline on lifestyle management to reduce cardiovascular risk [Electronic resource] / R.H. Eckel, J.M. Jakicic, J.D. Ard // Circulation. - 2013 .-- 46 p. - Mode of access to journal: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437740.48606.d1. full.pdf.
3. Campos-Outcalt D. The new cardiovascular disease prevention guidelines: what you need to know / D. Campos-Outcalt // J. Fam. Pract. - 2014. - Vol. 63, no. - P. 89-93.
4. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension [Electronic resource] / M.A. Weber, E.L. Schiffrin, W.B. White // J. Clin. Hypertens. - 2013. - Mode of access to magazines: http://www.ash-us.org/documents/ASH_ISH-Guidelinespdf.
5. ESH / ESC Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) / G. Mancia, R. Fagard, K. Narkiewicz // J. Hypertens. - 2013. - Vol. 31. - P.1281-1357.
6. Evidence-Based guideline for the management of high blood pressure in adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) [Electronic resource] / R.А. James, S. Oparil, B.L. Carter // Amer. Med. Ass. - 2014. - Mode of access to journals: Http: //circ.ahajournals.org/content/124/18/2020.full.
7. Ruilope L. M. Long-term adherence to therapy: the clue to prevent hypertension consequences / L. M. Ruilope // Eur. Heart J. - 2013. - Vol.34. - P.2931-2932.

RCHRH (Republican Center for Development of Health Protection of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Hypertensive [hypertensive] ailments with major diseases of the heart and nirok (I13), hypertensive [hypertensive] ailments with major diseases of the heart (I12), hypertensive ailments of the heart [hypothermia] I10)

Cardiology

General information

Short description

recommended
expert joy
RSE on REM "Republican center for development of health protection"
Ministry of Health Protection and Social Development of the Republic of Kazakhstan
from "30" leaf fall 2015 to rock
Protocol No. 18

Arterial hypertension- chronically stable pivotal arterial vise, with any level of systolic arterial vise, even more than 140 mm Hg. Art., і (abo) the level of diastolic AT, which is expensive or more than 90 mm Hg. in people who do not accept antihypertensive drugs [Recommendations of the All-Union Health Protection Organization and the International Partnership for Hypertensives 1999 r].

I. Introductory part

Name of the protocol: Arterial hypertension.

Cody for MKX-10:

I 10 Essential (primary) hypertension;

I 11 Hypertensive ailment of the heart

I 12 Hypertensive (hypertonic) ailment with major lesions of nirok;

I 13 Hypertensive (hypertensive) ailment with major lesions of the heart and nirok.

Fast, as vikoristoyutsya in the protocol: Wonderful Dodatok 1 clinical protocol.

Date of release to the protocol: 2015 рік.

to the protocol: Lіkarі of foreign practice, therapists, cardiologists, endocrinologists, nephrologists, ophthalmologists, neuropathologists.

Classification

CLINIC CLASSIFICATION

Table 1- Classification of Rivniv AT (mm Hg)

Note: The category of AD is assigned to a higher level of arterial vise, systolic or diastolic. Isolated systolic hypertension is guilty of classification at 1, 2, or 3 steps, according to the level of systolic arterial vise.

Heart-vascular disease is susceptible to the development of various categories of arterial pressure, the manifestation of heart-vascular factors in the disease, asymptomatic damage to organ-targets, high-grade diabetics, chronic heart disease

Table 2- Stratification of the out-of-town SS rizik on the category


Note: In hypertensive patients without symptoms and without manifestation of ZSSS, HHN, SD, as a minimum, a stratification of the outgoing SS is required for the study of the SCORE model.

Factors, at the premises of which the stratification of the risk is carried out, are presented in table 3.

Table 3- Factories, to pour into the forecast of the heart-vascular rhizik

Note: * - maximum risk for concentric HLS: adjustment of the LVL index when the growth rate is up to radius, equal to 0.42.

In ailments with hypertension, without heart disease, chronic heart failure and diabetic diabetes stratification of rhizic is carried out according to an additional model of systematic assessment of coronary rhizic (SCORE).

Table 4 Assessment of zagalny cardiovascular rhiziku

diagnostics

II. METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND LIKUVANNIA

Switching the main and additional diagnostic entries

Outpatient health care :

1). Vimіryuvannya arterial vise in the office of the doctor or the office (office) and the posture of the office (DMAD and DMAT) are presented in tables 6, 7, 8, 9.

Office AT - arterial vice, vimiryaniy in medical mortgage... The branch of the official AT is in an independent, uninterrupted connection with the frequency of insult, myocardial infarction, raptor death, heart failure, peripheral arteries, thermal stage of all ailments of these

Table 6- The rules of official vimіryuvannya arterial vise

AT posture with a medical setting to evaluate for the help of additional monitoring of AT (DMAT) or home vimiruvannya arterial vise (DMAD), in case of a vimiryuvannya you will be prompted to vibrate by the patient himself. Self-control of the arterial grip of the visualization of a medical doctor.

Table 7- Viznachennya arterial hypertension according to the official and official values ​​of AT

The control of AT posture with a medical device can change, so a large number of indicators of the arterial vise is given, which allows a greater assessment of AT in the context of official AT. DMAT and DMAD give some information about the status of the AT of the patient and about his risk and guilt to look, as to add one to one. Dani, otrimani about the methods, to finish the rules.

Table 8-Klinichna is shown for the Poseofisnaya vimіryuvannya arterial vise in diagnostics purposes

"Hypertension of a white dressing gown" is a camp, when at repeated opening-scent of the AT mortuary, we appear to be moved, and the pose of him, with DMAT or DMAD, is normal. They have a low heart-blister rhizik, low in patients with stiykoyu hypertension, especially when they have diabetes, deterioration of the organs of targets, heart-blister ailments and XXN.

"Maskovana hypertension" is a stun, at which arterial grip can be normal in office and pathologically adjusting the posture by means of a pawning, but the heart-vascular rhizik is in the range, which is typical of the hypertension. The term is recommended to be victorious for the patients who do not get the treatment.

Table 9- Rules of Poseofisné vimiruvannya arterial vise (DMAD and DMAT)

2) Laboratory and instrumental provision:

Hemoglobin і / hematocrit;

Analysis of the slaughter: microscopic slaughter siege, microalbuminuria, assignment of a protein for an additional test-male (I B).

Biochemical analysis:

The value of glucose in blood plasma;

Viznachennya cholesterol, cholesterol LDL, cholesterol HDL, TG in syrovattsі blood;

Viznachennya kaliyu and sodium in syrovattsi blood;

Viznachennya sečovaya acid in syrovattsі blood;

Blood serum creatinine value (with GFR rate) (I B).

EKG in 12 standard entries (IC);

Echocardiography (IIaB).

Dodatkovy doslіdzhennya on an outpatient basis:

Glycosylation of hemoglobin (even glucose in plasma more> 5.6 mmol / l (102 mg / dl) in two analyzes or earlier than existing diabetes mellitus) - for confirmation or vyklyuchennya diabetics;

The value of the test in the section (if not) with a positive result of the test in the section (even if the express analysis is positive) - for the detection of XXN;

Concentration of sodium and calories in the section and during treatment - for the prevention of primary or secondary hyperaldosteronism (IB);

SMAD - for approval of AG;

Dobove EHC Holter monitoring - to establish the nature of arrhythmias;

Ultrasound diagnostics of sleepy arteries (tovschini іntimu-media) (IIaB) - for detecting atherosclerosis and plaques in sleepy arteries;

Doppler ultrasonography of the vertebrae and peripheral arteries (IIaB) - for the detection of atherosclerosis;

Vimіryuvannya shvidkostі pulse hviliі (IIaB) - for the designation of aortic dysfunction;

Vimіryuvannya of the lumpy-brachial index (IIaB) - for the designation of the stage of the lesion of the peripheral arteries and atherosclerosis in general;

Inspection of the face-to-face bottom (IIaB) - for the detection of hypertensive retinopathy.

A minimal change in obsozhennya, which is necessary to carry out when directed to a planned hospitalization: according to the internal regulations of the stationary with respect to the orderly order placed by the body in the health protection.

The main (obov'yazkov_) diagnostics of the situation, which is carried out at a stationary(During hospitalization, diagnostics are carried out, but not carried out on an outpatient basis).

Loss of death is a sign of damage to the brain CT and MRI (IIb C), heart (echocardiography (IIa B), nirok (microscopy of slash siege, microalbuminuria, identification of a protein test for an additional trial black emptying and peripheral arteries, vimіryuvannya svidkostі pulse hvilya and lodgiac-brachial index (IIa B) oboviscous with resistant and accelerated hypertension.

Additional diagnostics, which should be carried out at a stationary hospital (during hospitalization, diagnostics are carried out, but not carried out at an outpatient hospital).

Transfer of the main and additional diagnostic visits to the stages of medical aid

The main (obov'yazkovy) diagnostics of the condition, which is carried out at the stage of medical aid :

Vimіryuvannya arterial vise (table 6) and pulse;

EKG in 12 standard entries.

Diagnostic criteria for setting a diagnosis

Pochatkove, patient care from AG maє buti is straight on:

Confirmation of hypertension diagnosis;

Revealing the causes of secondary hypertension;

Assessment of the heart-vascular rhizik, the level of organ-targets and clinically manifestous heart-vascular diseases.

For the whole it is necessary: ​​to check an arterial vise, an anamnesis, including a family history, a physical examination, laboratory analyzes and additional diagnostics.

Skargi and anamnesis(Table 10)

Z'yasuvati the manifestation of skarg:

A) on the head b_l, zapamorochennya, ruined dawn, sensitive or rukhov_ ruined;

B) on the bile in the breasts, badness, obscurity, heart rate, arrhythmias, nagryak gomilok;

C) for sprague, polyuria, nocturia, hematuria;

D) on cold cuts, change in culture;

D) for chropinnya.

When taking a medical history, you should establish:

Hour of staging the first diagnosis of hypertension;

AT value last і in Danish hour;

Assess antihypertensive therapy in advance.

Table 10- Taking an individual and family medical history

physical condition(Table 11).
In case of physical obsolescence, it is necessary to carry out the statement of abnormal diagnosis of hypertension (Table 6), the identification of SS risk, sign of the secondary nature of hypertension and organ damage. With palpation of the pulse and auscultation of the heart, arrhythmias can be detected. All patients are guilty of butyviryana's heart frequency is very fast in the country of calm. Takhіkardіya vkazu on changes in risik sickness of the heart. Irregular pulse can cause fibrillation of the anterior heart (including asymptomatic). Dodatkov, the fixation for the joke of the sudin is shown in the same way, as when the AT vimіryuvannya on both hands, the increase in SBP> 20 mm Hg appears. i DAT> 10 mm Hg

Table 11- Dates of the physical condition, which indicate pathology on the organ and the secondary nature of hypertension

laboratory criteria
The laboratory and instrumental rigor is focused on eliminating the tribute about the manifestation of additional factors in the development, the reduction of target organisms and secondary hypertension. The post-confession is carried out in the order of the simplest to the most common. details laboratory dosages presented below in tables 12.

Table 12-Laboratory criteria of factors, scho injected into the prognosis of the heart rhizic

Instrumental criteria:

Adjusted value of AT (div. Table 7);

EKG in 12 standard entries (index of Sokolov-Layon

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

Echocardiography (GLSH-index LVL:> 115 g / m2, in choloviks,> 95 g / m2, in women) (IIaB);

Ultrasound diagnosis of sleepy arteries (anti-media> 0.9 mm) or plaque (IIaB);

Pulse rate change> 10 m / s (IIaB);

Vimіryuvannya of the shoulder-brachial index<0,9 (IIaB);

Bleeding abo eksudati, swelling of the nipple of the healthy nerve during fundoscopy (IIaB).

Shown for consultation fahivtsiv

A. Neuropathologist:

1 state breakdown of cerebral blood circulation

Insult (ischemic, hemorrhagic);

Minuschі damage to cerebral blood flow.

2. Chronic forms of the brain pathology:

On the cob, show lack of blood supply to the brain;

Dyscirculatory encephalopathy.

B. Oculist:

Bloodshot into the sieve;

Nabrek of the nipple of the zorotic nerve;

Visiting the link;

Progressive vrata dawn.

B. Nephrologist:

Vinatok of symptomatic NEPHROGENIC hypertension, XXN IV-V century.

G. Endocrinologist:

Vinatok of symptomatic endocrine hypertension, diabetes mellitus.

Differential diagnosis

Differential diagnosis(Table 13)

For all ailments, it is necessary to conduct screening for secondary forms of hypertension, which includes a selection of clinical history, physical examination and routine laboratory analysis (Table 13).

Table 13- Clinical signs and diagnostics of secondary hypertension

Likuvannya beyond the cordon

Take a lykuvannya in Korea, Izrail, Nimechchin, USA

Otrimati the consultation on medturism

lykuvannya

Cіlі lіkuvannya:

The maximum reduction in the risk of development of the MTR and death;

Correction of all modified FR (curriculum, dislipademia, hyperglycemia, obesity);

Improvement, trusting the pace of progress and / or change in POM;

Lіkuvannya klinіchno manіfestnyh and fellow patients - ІХС, ХСН, СД, etc .;

Dosyagnennya tsilovih ravniv AT<140/90 мм.рт.ст. (IA);

Dosyagnennya at the sick at the Central House of Tsilovikh Rivniv AT<140/85 мм.рт.ст. (IA).

Likuvannya tactics:

Modification of the way of life: concordance of salt, concordance with alcohol, reduction of weight, regular physical activity, recollection of course (Table 14).

A Class of recommendations
b Level of proof
c As soon as


d Backed up on injection to HELL and SS Rizik
e Baseline on previous results

Drug treatment(Tables 15-16, babies 1-2, Dodatok 2 of the clinical protocol).

All the main groups of drugs are diuretics (thiazidi, chlorthalidone and indapamide), beta-blockers, calcium antagonists, angiotensin inhibitors and angiotensin receptor blockers to take therapy and are recommended for combined antihypertensive therapy (IA).

Deyak_ preparations are adequately respected for specific situations, so as the stench of vikorisovyvatsya in these situations in the classroom preliminaries or demonstrated greater efficiency in specific types of organ damage-targets (Tables IIaC).

Table 15- Become, wimagayut the vibrator of the drug

Fast: ACE - angiotensin-converting enzyme, ARB - angiotensin receptor blocker, AT - arterial vise, HHN - chronic ailment nirok, ISAG - isolated systolic arterial hypertension, HLSH - arterial hypertension

Monotherapy can effectively reduce the arterial squeeze less in a small number of ailments of hypertension (low and low heart-blister rhizic), and a large number of patients for the control of AT requires a combination of two drugs.

Malunok 1- Go to the choice of monotherapy or combined therapy for hypertension.

Most widely used two-component combinations of drugs are shown on the diagram for baby 2.

baby 2- Can combine classes of antihypertensive drugs.

Green without interruption lines-bazhani combinіtsіі. We green with a contour-brown combination (with deyakim interconnected). Black dotted line - possible combinations, ale little vivcheni. Chervona line is not recommended combination. I want verapamil and diltiazem inodi to be stuck in combinations with beta-blockers to control the pulse in patients with fibrillation in the anterior heart, in some minds with beta-blockers, they are guilty of being stuck.

Table 16- Absolute and definite contraindication before the intake of antihypertensive drugs

Drug treatment, which is repaired on a stationary basis see vische (table 15-16, babies 1-2, Dodatok 2 of the clinical protocol).

Medication for treatment, which is to be repaired at the stage of high-quality non-emergency help

For this stage, short-term preparations, including those for parenteral administration of labetalol (not registered in the Republic of Kazakhstan), nitropruside sodium (not registered in the Republic of Kazakhstan), nikardipin, are not very important, however, furosemic Slid not to admit a high hypotonia and a change in the perfusion of vital organs, especially the brain.

Інші vidi lіkuvannya: Go to the league with new camps (tables 17-26).

Treatment tactics for hypertension "white coat" and masked hypertension

Individuals with a hypertonic "white dressing gown" are therapeutically involved in a completely different way of living, but for such solutions there is a dynamical caution (IIaC).

In patients with hypertension, a "white coat" with a higher heart-and-bladder rhizic, amumatized with metabolic disorders or asymptomatic lesions of target organisms, may be a preschool medication therapy before, on the pre-day period.

In case of masked hypertension, it is worthwhile to prescribe antihypertensive drug therapy in a different way of life, as it has been repeatedly established that the hypertension type is characterized by a heart-blistering rhizic, even close to that in official A.

The tactics of antihypertensive therapy in the sick of the abducted and old man are presented in Table 17.

Table 17- Tactics of antihypertensive therapy in the sick of the kidnapped and old man

Young adults... In a single adhesion of the brachial systolic vise in young people (with DAP<90 мм рт.ст), центральное АД у них чаще всего в норме и им рекомендуется только модификация образа жизни. Медикаментозная терапия может быть обоснованной и целесообразной, и, особенно при наличии других факторов риска, АД должно быть снижено до<140/90 мм.рт.ст.

Antihypertensive therapy in women... It is recommended that drug therapy be prescribed for severe arterial hypertension (SAT> 160 mm Hg or DAP> 110 mm Hg) (IC), Table 18.

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

Table 19- Antihypertensive therapy for MS

Tactics of the management of patients with hypertension in case of diabetes mellitus(Table 20).

Tsilove value of AT<140/85 мм.рт.ст (IA).

Table 20- Antihypertensive therapy for diabetes mellitus

Tactics for the management of patients with nephropathy(Table 21).

Table 21- Antihypertensive therapy for nephropathy

Fast: AT - arterial vise, RAS - renin-angiotensin system, HHN - chronic ailment nirok, GFR - glomerular filtration rate, GARDEN - systolic arterial vise.

Treatment tactics for cerebrovascular ailments(Table 22).

Table 22-Antihypertensive therapy for cerebrovascular disease

Fast: AT - arterial vise, GARDEN - systolic arterial vise, TIA - transient ischemic attack.

Tactics of getting sick of the sick AG iz getting sick of the heart.

TSILOVE GARDEN: <140 мм.рт.ст. (IIaB), таблица 23.

Table 23- Antihypertensive therapy for heart disease

Fast: ACE - angiotensin-converting enzyme, ARB-blockers of angiotensin receptors, HLS - hypertrophy of the lone slurry, SBP - systolic arterial vise.

Tactics for treating ailments of hypertension in atherosclerosis, arteriosclerosis and severe peripheral arteries.
TSILOVE GARDEN: <140/90 мм.рт.ст. (IА), так как у них имеется высокий риск инфаркта миокарда, инсульта, сердечной недостаточности и сердечно-сосудистой смерти (таблица 24).

Table 24- Antihypertensive therapy for atherosclerosis, arterio-sclerosis and peripheral arteries

Fast: ACE - angiotensin-converting enzyme, AT - arterial vise, PPA lesion of the peripheral arteries, SPV - pulse hvily speed.

Treatment tactics for resistant hypertension(Table 25).

Table 25- Antihypertensive therapy for resistant hypertension

Fast: DMAT - dobové outpatient monitoring of arterial vise, AT - arterial vise, DAT - diastolic arterial vise, GARDEN - systolic arterial vise.

malignant hypertensionє In a non-loose camp, it is clinically manifested as a sign of the advancement of an arterial vise in the same with ischemic attacks of organ-targets (sits, nirok, heart or GM). Due to the low incidence of the given stan, no control over the new drugs was carried out. The current therapy is based on drugs, which can be indicated internally with titration of the dose, so that it allows the action quickly, albeit smoothly, to unify the development of the low hypotonia and the improvement of the ischemic lesion of the target organs. In the middle of the most frequently implanted preparations for internal medicine for important patients - labetalol, sodium nitropruside, nicardin, nitrate and furosemide... Vibir to the drug is carried out on the examination of the drug. However, diuretics cannot cope with the amount of money needed, because ultrafiltration can be helpful, or even time-consuming dialysis.

Hypertensive crisis and incapacitated patients... Prior to inconvenient situations in hypertension, the incidence of MAP or DAP (> 180 mm Hg, or> 120 mm Hg, apparently) is observed, which may lead to a threat or progression

Damage to organs-targets, for example, with swelling neurological signs, hypertensive encephalopathy, cerebral infarction, internal cranial hemorrhage, guest lvoshlunochkovy lack of lightness, and a good amount of heart disease

Іzolovane rіzke pіdvischennya arterіalnogo vise without Find our GOSTR urazhennya organіv-mіsheney (gіpertonіchny crisis), often rozvivaєtsya on tlі Pererva in terapії, znizhennya Dozy preparatіv and takozh trivogi scho not vіdnosyatsya to nevіdkladnih situatsіy i pіdlyagaє korektsії Shlyakhov vіdnovlennya abo іntensifіkatsії medikamentoznoї terapії i kupіruvannya anxiety.

Hirurgicne involvement .
Endovascular treatment of resistant hypertension-catheter ablation of sympathetic plexus of the nirkova artery, or nircovascular denervation of the bilateral nerve plexus, how to use the reins of the nirkova artery through the introduction of radio frequency catheterization through the introduction of radio frequency ablation The mechanism of this engaging polyagus in the damaged of a pretty one flowing onto the support of nirkovy vessels, in the appearance of renin and reabsorption of sodium, and in the reduction of a sympathetic tone in the nirk and the other organs

Shown before the procedureє resistant uncontrolled esential AH (systolic AT with vimiruvanny office and DMAD - ponad 160 mm Hg or 150 mm Hg - in patients with diabetic diabetics, confirmed / confirmed 80 mm Hg. ≥130 Table 7), without affecting the tri-component therapy carried out by the Fakhivts from AH (Table 25), and the patient's preoccupation before treatment.

Prototypes shown before the procedureє nirkovy arteries less than 4 mm in diameter and less than 20 mm per second, manipulation on nirkovy arteries (angioplasty, stenting) in anamnesis, stenosis of nirkovy arteries more than 50%, nirkoval deficiency (hr. Sudden podії (IM, epizod of unstable angina, transient ischemic attack, insult) less than 6 m / s. before the procedure, be it the second form of the hypertension.

professional come in(Prevention accelerated, the primary preventive measure for the level of PMSD, due to the significant factors in the risk):
- home monitoring AT (DMAD);

Diet with food fat, bagata kalim;

Change of implantation of kitchen salt (NaCI) up to 4.5 g / dobu;

Decreased excess oil;

Allowance for alcohol consumption;

Regular dynamic physical renewal;

Psychorelaxation;

Preceding the regime of pratsi and rescuing;

Groups of employment in AG schools;

Dotrimannya regimen of drug intake.

Lіkuvannya factorіv risiku, assocіyovanyh s AG(Table 26).

Table 26- Likuvannya factors in risik, mated with hypertension

Further the tactics of the medical doctor :

Achievement and adjustment of the AT.

When antihypertensive therapy is recognized, plans to take a sick person to a doctor for assessing the tolerance, efficiency and safety of treatment, as well as monitoring the selection of recommendations, should be carried out with an interval of 2-4 days to the maximum

Pislya to reach the whole level of AT at the same therapy onset of the visit for patients from middle to low risik, Planned with an interval of 6 months.

for the sick with a high і even a high risik, і for individuals with a low habits to lіkuvannya Intervals between innocent visits for 3 months.

On all planned visits, it is necessary to control the visitor's recommendations for treatment. Oskilki stan of organ-targets change every now and then, the control of the patient for clarification will not be carried out frequently more than 1 time at the rick.

for people with a high normal AT or a hypertonic "white dressing gown" If the stench doesn’t take away the therapy, it’s followed regularly (as minimum 1 time per day) with official and outpatient AT, as well as assessing the heart-suckling rhizic.

For the dynamic sparing of the victorious phone contacts with the patients for the improvement of the courtesy to the liking!

For polishing the dignity to the liking, it is necessary to have a ringing sound between the patient and the medical staff (self-management of the patient). For the sake of this, it is necessary to conduct home monitoring of AT (sms, e-mail, social networks or automated methods of telecommunication), directing for self-monitoring of self-control efficiency.

Indicators of the effectiveness of treatment and safety of methods of diagnosis and treatment, described in the protocol.

Table 27-Indicators of the effectiveness of treatment and safety of methods of diagnosis and treatment, described in the protocol

A. V. Bilchenko

9 worms within the framework of the Congress of the European Partnership for the Promotion of Arterial Hypertension (ESH);

Rating and classification of AG

The ESH / ESC experts have taken the decision to surrender without changes to the previous recommendation and the classification of the arterial vise (AT) in the fallowness from the standard, fixed in the case of the “official” type, in the case of “E. "," Very normal "і 3 stages of hypertension (recommendation class I, level of evidence C). With a large hypertension, there is an increase in the "office" systolic arterial vise (SAT) ≥140 mm Hg. Art. і / abo diastolic AT (DAP) ≥90 mm Hg. Art.

However, with a look at the importance of "Poseophysics" in the recognition of arterial pressure and recognition in the history of AT in patients with new methods of recognition in the ESH / ESC Recommendations for the recognition of the AG (2018), the classification is included for classification monitoring of AT (AMAD) (Table 1).

The introduction of this classification gives the possibility of diagnostics of hypertension on the basis of the diagnosis of arterial hypertension, as well as of the newer clinical forms of hypertension, the first for all the "disguised hypertension" and "disguised hypertension"

diagnostics

To establish the diagnosis of hypertension, it is recommended to re-"officially" check the arterial vise for the method, as it did not know the change, but the assessment of the "Poseofisne" vymeryvaniya arterial vise (home self-measurement, but in the case of AMAD) In such a rank, if "office" Vimir is recommended for screening detection of hypertension, for diagnostics, it is possible to use the method of Pozaophisne vimiruvannya arterial vise. It is recommended to carry out in singing clinical situations Poseofisné vimiruvannya arterial vise (home self-measurement and / abo AMAD) (Table 2).

In addition, AMAD is recommended for assessing the level of arterial pressure at night and the stage of its lowering (in people with low apnea, diabetes mellitus (CD), chronic ailments nirok (HHN), endocrine distention forms of hypotension)

When a screening re-examination of the "office" AT is carried out according to the amount of evidence disclosed in the ESH / ESC Recommendations from the AG (2018) proponents, an algorithm for diagnostics from victories of the other methods.

Nevirishenim, from the point of view of the ESH / ESC experts, need to be fed about those methods of reducing the arterial clutch in ailments with a permanent form of fibrillation in front of the heart. Similarly, there are tributes of the great historical experiences, and of those who do not know about the methods Poseophysically changing the arterial grip is possible to predict the great cardiovascular therapies in the periodical controlled

Assessment of cardiovascular risk and reduction

The methodology for assessing the total SS risk has not known a change and is more commonly presented in the ESC Recommendations on the Problem of Cardiovascular Disorders (2016). Proponent for assessment of the risk in patients with AG of the 1st stage vicoristovuvati the European scale of assessment of the risk of SCORE. However, it may be possible to pour it on the total SS risk in an ailing hypertension if the factor is not reflected in the SCORE scale.

The number of factors introduced into the risk of new, such as the level of secular acid, early menopause in women, psychosocial and socially-economical officials, the frequency of heart rate (HR) in calm> 80 beats. / Xv (Table 3).

Also, on the assessment of SS risk in patients with hypertension, injecting the presence of organ target (POM) and diagnosing SS disease, SD or ailment nirok. The ESH / ESC recommendation (2018) did not include significant changes in the POM appearance in the AH patients.

Yak i ranіshe proponuyutsya bazisnі test: elektrokardіografіchne (EHC) doslіdzhennya 12 standard vіdvedennyah, viznachennya spіvvіdnoshennya albumіn / kreatinіn in sechі, rozrahunok shvidkostі klubochkovoї fіltratsії for rіvnem kreatinіnu plasma fundoskopіyu i number dodatkovih metodіv for bіlsh detailed viyavlennya SIP zokrema ehokardіografіya for otsіnki gіpertrofії livogo shlunochka (GLSH), ultrasonography for the assessment of the product to the complex of anti-media sleep arteries and in.

Slid of memory about the low sensitivity to the EKG method for detecting GLSH. So, with the victorian index of Sokolov - Lyon, sensitivity becomes only 11%. This means a large number of hibno-negative results in diagnosed HLS, even if the EKG is negative, the echocardiography with the myocardial mass index should not be performed beforehand.

The classification of the stages of hypertension is proponated with the level of arterial vise, the manifestation of the POM, the concomitant ailments and the total SS rhizik (Table 4).

A classification is given that allows the assessment of the sick not only for the level of the arterial grip, but for everything behind the total SS risk.

It should be borne in mind that the ailments have a lack of only a decrease in AT. Obov'yazkovuyu for them є the sign of statin, which do not lower by a third of the risk of myocardial infarction and a quarter of the risk of stroke when the control of the arterial grip is reached. It also means that the analogous cinnamon bullet is stretched out when statins are consumed in ailments and with a higher low rhizik. The given recommendation significantly expands the indication of statins in patients with hypertension.

On the contrary, it is indicated for the intake of antiplatelet drugs (in front of low doses of acetylsalicylic acid), combined with secondary prophylaxis. Їх zasosuvannya is recommended only we are sick with diagnosed SS sickness and not recommended we are sick AH without SS sickness is directly from the total rhizik.

INITIATION OF THERAPY

Going to the initiation of therapy, the ailments of the hypertension have become aware of a hundred wines. The appearance in a sickly arched SS with a high normal AT (Fig. 2).

The initiation of pharmacotherapy is also recommended for people with illnesses older than 65 years, and not older than 90. However, the use of pharmacotherapy with antihypertensive drugs is not recommended for people with 90 years of illness, so that they can tolerate the stench.

Tsilovy Rivn AT

The change of the AT mains was actively discussed over the course of the last 5 years, and in fact, it was announced during the preparation of the recommendations of the United States Committee on Prevention, Diagnostics and Diagnostics of the Intervention. Experts, who were preparing the JNC Recommendations 8, came to the meeting, and the observational earlier showed an increase in the cardiovascular rhizic even if the SAT level was ≥115 mm Hg. Art., and in randomized prescriptions with antihypertensive drugs in the form of antihypertensive drugs, the cinnamon was actually brought to the level of ≤150 mm Hg. Art. ...

For the update of this nutrition, the SPRINT was updated, 9361 ailments of the high SS rhizik with GARDEN ≥130 mm Hg were included in the yak bully. Art. without SD. The sick were divided into two groups, in one of the GARDEN they were reduced to the value<120 мм рт. ст. (интенсивная терапия), а во второй – ​<140 мм рт. ст. (стандартная терапия).

As a result, the number of great SS pods was 25% less in the intensive therapy group. The results of the recent SPRINT became a proof base for the published in 2017 new American recommendations, which set the goals for lowering the GARDEN.<130 мм рт. ст. для всех больных АГ с установленным СС заболеванием или расчетным риском СС событий >10% in the nearest 10 years.

The ESH / ESC expertise is applied, but in the previous SPRINT the arterial vise was carried out according to the methodology, as it was learned from the traditional methods of testing, and the same:

With this method, the level of the arterial vise is lower, lower with the "office" AT by approximately 5-15 mm Hg. st. In fact, we will equal the arterial clutch, reached in the group of intensive therapy in the pre-SPRINT, approximately the level of SBP 130-140 mm Hg. Art. with the "official" Vimir AT at the lykar.

In addition, authorize the ESH / ESC Recommendations from the AG (2018) to support the great meta-analyzes, showing the mean value of the decrease in SBP by 10 mm Hg. Art. with an outward SBP 130-139 mm Hg. Art. (Table 5).

Similar results will be eliminated in one meta-analysis, which, in addition, by showing a mean value due to a decrease in DAT<80 мм рт. ст. .

On the basis of these dosages in the ESH / ESC Recommendations from the Likuvannya AG (2018) for all ailments of the AG, a target level of lowering the GARDEN has been established<140 мм рт. ст., что несколько отличает на первый взгляд новые европейские рекомендации от рекомендаций, принятых в 2017 году в США , которые определили для всех больных АГ целевой уровень САД <130 мм рт. ст.

However, the European experts were able to interpret the algorithm for reaching the entire AT ryvn, as well as at the same time as the SAD rallies.<140 мм рт. ст. и хорошей переносимости терапии следует снизить уровень САД <130 мм рт. ст. (табл. 6). Таким образом, этот алгоритм фактически устанавливает целевой уровень САД <130 мм рт. ст., однако разбивает на два этапа процесс его достижения.

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

Able on the group podil to make the deyakі clarification in the central part of the GARDEN. So, for ailments of 65 years and older, it is recommended to reach the whole level of SAT from 130 to<140 мм рт. ст., а у больных до 65 лет рекомендуется более жесткий контроль АД и достижение целевого САД от 120 до <130 мм рт. ст.

Also recommendations strict control of the goals of the central GARDEN<130 мм рт. ст. у больных с сопутствующим СД или ишемической болезнью сердца. Достижение целевого уровня САД от 120 до <130 мм рт. ст. также рекомендовано больным после перенесенного инсульта или транзиторной ишемической атаки, однако класс рекомендации более низкий, как и уровень доказательств.

For ailments іf ХХН recommendations, there is less strict control of AT from the reach of the central SBP from 130 to<140 мм рт. ст. Таким образом, для большинства больных АГ рекомендован целевой уровень САД <130 мм рт. ст. при офисном измерении АД за исключением пациентов от 65 лет и старше и больных с сопутствующей ХБП, что фактически максимально приближает новые Рекомендации ESH/ESC по лечению АГ (2018) к опубликованным в 2017 году американским рекомендациям .

Reaching the control of the arterial grip from the ailments will become foldable. In most cases in the regions of Europe, AT is controlled by less than 50% of the sick. I will look at the new goals of AT, the ineffectiveness of monotherapy in a greater number of cases and a decrease in the lability of ailments to the proportion of the number of acceptable tablets, the proponents of the onset algorithm of the delayed control.

1. AG can be diagnosed at the show not only "office", but "Pozaofisne" in the form of arterial vise.
2. Pharmacotherapy in patients with high normal AT in ailments with a very high SS rhizic, as well as in ailments with 1 stage of AH and a low SS rhizic, as the way of life does not lead to the control of arterial grip. An ear of pharmacotherapy in ailments of a kidnapped viku, how to endure the stench and goodness.
3. Establishment of the central level SAT<130 мм рт. ст. у большинства больных, достигаемого в два этапа, после снижения САД <140 мм рт. ст. и хорошей переносимости терапии.
4. A new algorithm for reaching the control of AT in ailments.

literature

1. Williams, Mancia, et al. 2018 ESH / ESC Guidelines for the management of arterial hypertension. European Heart Journal. 2018, in press.
2. Piepoli MF, Hoes AW, Agewall S., Albus C., Brotons C., Catapano AL, Cooney MT, Corra U., Cosyns B., Deaton C., Graham I., Hall MS, Hobbs F. DR, Lochen ML , Lollgen H., Marques-Vidal P., Perk J., Prescott E., Redon J., Richter DJ, Sattar N., Smulders Y., Tiberi M., van der Worp HB, van Dis I., Verschuren W . MM, Binno S. ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Heart Journal. 2016. Aug 1; 37 (29): 2315-2381.
3. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014; 311 (5): 507-520.
4. The SPRINT Research Group. N. Engl. J. Med. 2015; 373: 2103-2116.
5. Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Dennison Himmelfarb C., DePalma SM, Gidding S., Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P., Ovbiagele B., Smith SC Jr. , Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr., Williamson JD, Wright JT Jr. 2017 ACC / AHA / AAPA / ABC / ACPM / AGS / APhA / ASH / ASPC / NMA / PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology / American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;
   71 (6): e13-e115.
6. Ettehad D., Emdin CA, Kiran A., Anderson SG, Callender T., Emberson J., Chalmers J., Rodgers A., Rahimi K. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta- analysis. Lancet. 2016. Mar 5; 387 (10022): 957-967.
7. Thomopoulos C., Parati G., Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels - updated overview and meta-analyzes of randomized trials. J. Hypertens. 2016. Apr; 34 (4): 613-22

Karpov Yu.A. Starostin I.V.

Entry

At the worm 2013 G... at the Schorichniy European Conference arterial hypertension(Ah) boules presented new recommendations by її lykuvannyu... with the European partnership for hypertension(EOG, ESH) and the European Society of Cardiologists (EOK, ESC). Stink є Continued recommendations from 2003 and 2007 pp... new additions in 2009 G... ... ci recommendations Saving the decline the main principles: based on the correct test reports, knowledge of the all-in-one analysis of literature, the priority of randomized controls, and the recommendations(Table 1) and the level of evidence (Table 2). recommendations vibrated for 18 ms. and before the visions of the boules, two were seen by 42 European fakhivtsy (21 types of Skin Partnership).

In the Danish hour Russian medical partnership for arterial hypertension(RMOAG), affiliated with the European Partnership for AG, preparation is ready until the last version of the given recommendations is seen.

new aspect

1. new Epidemiological data on AG and control in the regions of Europe.

2. Insight into the greater predictive value of home monitoring arterial vice (DMAD) and its role in diagnostics lykuvanni AG.

3. new data about the inflow on the forecast the value of no AT, "hypertension of a white dressing gown" and masking hypertension .

4. Assessment of zagalny heart-vascular rhizicum - greater emphasis on the value of AT, heart-vascular factor rhizik, asymptomatic reduction of organ-targets and clinical acceleration.

5. New data about the infusion of asymptomatic lesion of organs-targets, including the heart, judgment, nirki, eyes and brain, for the prognosis.

6. Clarification of the risik, tied with an overworld body of tila, and the whole meaning of the index of masi tila (IMT) in hypertension.

7. AH in children of a young age.

8. Ear of antihypertensive therapy. Advancement of evidence of criteria and reduction of drug therapy in high normal AT.

9. Significance for blood pressure therapy. Unified values ​​of systolic arterial vise (SAD) (<140 мм рт.ст.) у пациентов из группы как с высоким, так и с низким сердечно-сосудистым риском.

10. Vilny pidhid before the cob monotherapy, without any ranking of the preparations.

11. change scheme of bazhanih combination of two preparations.

12. New therapy algorithms for reaching target AT.

13. Updates on tactics lykuvannya in special situations.

15. Drug therapy in individuals over 80 years old.

16. Especially respect for resistant hypertension, new go to її lіkuvannya.

17. Strengthening the respect for therapy with the training of target organisms.

18. New to the trivial (chronic) therapy of hypertension.

Dal in the statistics will be the most important, in our opinion, snakes in accordance with the previous recommendations, which can be used for a wide range of drugs and sciences, and serve as a "road map" for more detailed implementation of the other version of the recommendations. For a new version of your recommendations, you can check the official website of the Russian Medical Association for AG - www.gipertonik.ru.

New Epidemiological Data on AG

One of the shortest surrogate indicators, which is to visualize the situation with the hypertension, is the insult and the mortality of a person. In the provinces of western Europe, there is a decrease in the frequency of strokes and mortality from them, at that time in the western European lands, incl. in Russia (from 1990 to 2006), the mortality rate from insult until the last hour was reduced and only in the last 3 years began to decrease.

Poseoffice monitoring of AT

If you do not need to monitor AT (DMAT), do not need to monitor AT (DMAT). Pozaofіsne vimіryuvannya arterial vise can be a number of perevag, which was shown in the new recommendations on AG from 2013 m Mainly among them - a greater number of vimiryuvans, which more beautifully depicts the real situation from AT, less vimiryuvannya at the car. Besides, on an outpatient basis snake AT is more beautiful, less of an official concern with such markers of destruction of organ-targets in ailments of hypertension, such as hypertrophy of a louse (HLS), a combination of anti-media sleepy artery and death. Tsikavo, scho transfer Pozaofisne monitored AT is found in the foreign population, as well as in other groups: among the ailments of the young and old age, in particular both articles, they are known to be on medication, such as osob with heart-and-death sickness and sickness nirok. It is also established that low AT is a strong predictor, low. For new recommendations, adhere to the key meaning of the type snakes nichny AT (so-called "dipping") for the Danish moment before the end is not assigned, to that the date of the change of the heart-and-heart rhizik in particular with the swirling "dipping" is not uniform.

In the present hour, there are recommendations, which can be traced back to the DMAD. Having taken aside the methodological nutrition of the DMAD, it means that telemonitoring and supplements for DMAD to smartphones are included in the household, and the interpretation of the results and the correction of the guilt, conducting the madness On the basis of the DMAT, the DMAD allows the assessment of AT for a trivial hour and is not associated with fewer vitrates, but does not allow the assessment of any AT value, the assessment of the AT in prominence in a short period of time. It means that the DMAD is not better, not the DMAT, I can relate to the target organ damage and I can predict the same value.

Vibir of the technique of vimiruvannya arterial vise posture by office (DMAT or DMAD) to lay down in a specific situation. So, in case of polyclinical caution, logical DMAD will be victorious, at that hour the DMAT may be victorious in case of near-Cordon abnormal results of DMAD. Within the framework of a special additional assistance, logical viglyadak vikoristannya SMAD. In both cases, trivial control of the effectiveness of the treatment of sickness without DMAD. Clinical is shown to the position of the arterial vise presented in table 3.

Isolated office of AG

(Abo "hypertension of a white robe")

and masked by AG

(Abo Isolovana outpatient hypertension)

DMAT і DMAD є by standard methods of detecting given nosological forms. At the connection with the adhered cymbal methods of vimіryuvannya arterial vise vіdmіnіnіy vіdnіnnіyu "hypertension of a white dressing gown" і “masked hypertension & raquo;, Diagnosed by the method of DMAT and DMAD, are taken into account in general. The subject of debate is nutrition, which can be brought from the "hypertonic white dressing gown" to the true norms. In young people, in particular, with the given camp of testimony, there is an intermediate level of hypertension and true normotensiveness of the distance between the heart and the vertebral column. At the same time, for the given metaanalysis, how to become secure, when the factor is involved, the heart-and-heart rizik in case of "hypertension of the white dressing gown", the sutta does not seem to be of such kind in the case of true normotonia; However, the whole thing is tied with likuvannyam, I will take away a part of the tsikh ailments. The diagnosis of "hypertension of a white coat" is recommended to be confirmed not less than in 3-6 months. as well as it is a good thing to be in good health and to support the danikh patients.

According to data from populaces, the width of masked hypertension is 13% (range from 10 to 17%). Metaanalysis of prospective reports about dvorazov, due to the normotensiveness, growing heart-and-vessel congestion in this case of illness, which is indicative of the stigma of the AG. We can give an explanation of the phenomenon of a bastard diagnosing a camp and, apparently, the appearance of a disease among those who are ill.

Ear of antihypertensive therapy

and values

good advice ESH / ESC 2007, antihypertensive therapy should begin to show we are ill with hypertension of the 1st stage without any other factors in the risk of developing target organisms, as drug therapy was unsuccessful. In addition, we are sick with diabetes, heart disease and chronic heart failure, antihypertensive therapy was recommended for the indication that the blood pressure should be in a high normal range (130-139 / 85-89 mm Hg).

In the last hour, there is little evidence of antihypertensive drug use for antihypertensive drug use from AH of the 1st stage of low and middle rhizik - there are not many people who have been diagnosed with a disease. However, in the recently published Cochrane meta-analysis (2012-CD006742), there was a tendency to a decrease in the frequency of insult on ailments from AH of the 1st stage, but in connection with a small number of ailments, the statistical significance was not significant. At the same hour, there was a number of arguments for the coughness of hypertension of the 1st stage to be taken with a low and medium level of risk, and the same: increased risk of sickness in patients with HIV tactics, inadequate efficiency of therapy for the number of heart disease , scho supravodzhutsya good spіvvіdnoshennyam "price - cinnamon".

Pidvischennya systolic arterial vise vische 140 mm Hg. with spared normal diastolic AT (<90 мм рт.ст.) у молодых здоровых мужчин не всегда сопровождается повышением центрального АД . Известно, что изолированная систолическая гипертония у молодых не всегда переходит в систолическую/диастолическую АГ , а доказательств, что антигипертензивная терапия принесет пользу, не существует. Таким образом, этих больных следует тщательно наблюдать и рекомендовать изменение образа жизни.

Likewise, changing and setting up antihypertensive therapy to the appointment of antihypertensive therapy, we are sick of a high and even high heart-vascular rhizik, tied to diabetes, congenital heart-vascular abnormalities, with high values ​​of 9-89 mm. ). The scanty evidence of the effectiveness of such an early medication does not allow us to recommend an ear of antihypertensive therapy for such ailments.

The number of AT values ​​for large groups of sick people becomes less than 140 mm Hg. for systolic arterial vise і less than 90 mm Hg. - for the diastolic. At the same hour, we have AH of a young and old age younger than 80 years old with an ear of corn GARDEN ≥160 mm Hg. it is recommended to lower the SBP to 140-150 mm Hg. ... At the same time, the zadovilny camp of the health of the group of groups is ill to rob the potential assistant to the lowering of the GARDEN<140 мм рт.ст. а у пациентов с ослабленным состоянием здоровья следует выбирать целевые значения САД в зависимости от переносимости. У больных старше 80 лет с исходным САД ≥160 мм рт.ст. рекомендовано его снижение до 140-150 мм рт.ст. при условии, что они находятся в удовлетворительном физическом и психическом состоянии . Больным диабетом рекомендуется снижение ДАД до значений менее 85 мм рт.ст. .

At the present moment, there are no randomized dosages of key points, as they have allowed the use of AT value in the course of their homeland and outpatient monitoring. Protest, for deyakim data, effective reduction of the official AT supervises not even more great indications Pozaofisné indicators. In other words, in this dosage it is shown that the decrease in arterial pressure (according to the data in the lesion) on the other<120 мм рт.ст.

Vibir antihypertensive therapy

Yak i in recommendations ESH / ESC 2003 і 2007 рр. , In the new recommendations, we should be sure to confirm the visibility of any class of antihypertensive drugs over those main perevagi antihypertensive therapy amalgamated to lower arterial grip like this. At zv'yazku of CIM novі rekomendatsії pіdtverdzhuyut vikoristannya dіuretikіv (vklyuchayuchi tіazidnі, chlorthalidone, indapamide i), β-blokatorіv, antagonіstіv kaltsіyu, іngіbіtorіv angіotenzinperetvoryuyuchogo enzyme (ACE) i blokatorіv retseptorіv angіotenzinu in yakostі pochatkovoї i pіdtrimuyuchoї mono- i kombіnovanoї terapії. In such a rank, there is no universal ranking of antihypertensive drugs in relation to the duration of the day.

The new recommendations have a firm grip on the effectiveness of a cob of combination of two drugs in ailments of high rhizic, or with even high high blood pressure. It is linked with this, that the combination of two antihypertensive drugs from the older classes, as showing the metaanalysis of more than 40 days, leads to a greater decrease in the arterial pressure, and the lower dosage during monotherapy. Combined therapy leads to a large decrease in AT in a large number of ailments, which is especially important for those with a high risk and with a high arterial grip. In addition, ailments, which accept a combined therapy, are seen from a history of earlier, lower ailments, as a monotherapy. Do not forget about synergistic drugs of different classes, but you can lead to a lesser turn of side effects. At the same hour, the therapy was combined for a short time, which seems to be in the potential ineffectiveness of one of the drugs in the combination, which is very important.

In case of ineffectiveness of monotherapy or a combination of two drugs, it is recommended to increase the dose until the whole AT is reached, even to the next dose. As long as the combination of two drugs in higher doses is not consumed, it is possible to add a third drug or transfer the sick person to the combined therapy. Slide memory, but in case of hypertension resistant to treatment, the addition of a skin preparation can be reduced as a result, if there is a lack of a drug, it will be reduced.

There are even more randomized clinical dosages of antihypertensive therapy in combination with antihypertensive drug combinations, in case of three of them, a specific combination of antihypertensive drugs was gradually taken into account. In pre-ADVANCE patients, a combination of an ACE inhibitor with a diuretic or placebo was given prior to the antihypertensive therapy. Pre-admission FEVER underwent preliminary combined therapy with a calcium antagonist and a diuretic with a monotherapy with a diuretic plus placebo. In the pre-admission ACCOMPLISH, a preliminary combination of an ACE inhibitor and a diuretic with the same ACE inhibitor and calcium antagonist was carried out. In all of the other pre-adolescents, the treatment in all groups was repaired with monotherapy, and if only some of the ailments were deprived of some of the ailments, a supplementary drug was removed, and do not expect only one. And in the pre-existing antihypertensive and hypo-polydemic therapy ALLHAT, the presenter self-selected another drug among them, since they were not vicarious in the other therapeutic group.

Protest, less than all antihypertensive combinations, were stashed as a minimum in one group of treatment in placebo-controlled patients, for the blame of angiotensin receptor blockers and calcium antagonists. In all types of patients, there are a lot of changes in the groups of active therapy. Moreover, in the case of the different regimes of the combined therapy, there were no specific indications. Both the combination of a receptor blocker for angiotensin and a diuretic, as well as a combination of calcium antagonist and an ACE inhibitor, have outperformed the combination of a β-blocker and diuretic in the number of serum lowering. At the same hour, in the ranks of those who have been advancing the combination of a β-blocker with a diuretic, the bullet is effective, as is the combination. In the case of pre-existing ACCOMPLISH, it was more significant for the ACE engineer in the combination with the calcium antagonist in front of the ACE engineer in the case of a diuretic, as opposed to a diuretic. It can be tied with a more effective way of the antagonist of calcium and the ingibitor of the AAS on the central vice. For data of ONTARGET and ALTITUDE, the combination of two RAAS blockers is not recommended.

The new recommendations have a desire to consume a combination of fixed doses of two and three antihypertensive drugs in one pill, which will lead to the addition of a sick person to addiction, and to mean control. It’s not a lot earlier that it’s unwise to change the dose of one of the components right away from the last step, so there’s more and more combinations with different doses of the components.

visnovok

In the tsy statty mi zupinilis deprived of a small part of quiet changes, as they know the recommendation for hypertension. On the other hand, after reading the whole article, you can also formulate the first hostility about the new recommendations, and simply forgive the knowledge about the new version, but it is necessary, madly, to all the faults, we will tie up the problem of AH.

literature

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11. Dolan E. Stanton A. Thijs L. et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study // Hypertension. 2005. Vol. 46. ​​P. p. 156-161.

12. Sega R. Facchetti R. Bombelli M. et al. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation. 2005. Vol.111. P. 1777-1783.

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New recommendations on arterial hypertension

Karpov Yu.A.

arterial hypertension(AH), being one of the main independent factors in the development of insult and heart disease (ІХС), as well as heart-vascular acceleration - myocardial infarction (IM) and heart failure, it is necessary to be considered a problem before ... For a successful fight against such extensions and inconvenient disabilities, a well thought out and organized program is necessary for the emergence and treatment. Such a program has become madly recommendations according to AG, as regularly, the world has new Danih, to exchange glances. 3 hour out in 2008 G... the third version of the Russian recommendations from prophylaxis, diagnostics and treatment of AG bully otrimanі new Dani, scho vimagayut to look at the document. The link with the cym of the initiative of the Russian Medical Association for AG (RMOAG) and the All-Russian Scientific Association of Cardiologists (VNOK) has recently been broken nova... the fourth version of the most important document, which went through a detailed discussion and in the future 2010 G... presented at the VNOK Congress.

This document was based on recommendations according to the Likuvannyu AG of the European Partnership for arterial hypertension(EOG) і European Association of Cardiologists (EOC) 2007 і 2009 pp... and the results of the great Russian reports on the problems of AG. So yak itself and in the previous versions recommendations... the value of AT is seen as one of the elements of the system and stratification of the zagalny (summarized) heart-vascular rhizik. When assessing zagalny heart-vascular rhizik, there is a great number of minors, and the value of AT is initial due to its high prognostic significance. At the same level of AT, there is the most regulated change in the system of stratification. How to show the safety, the effectiveness of the doctor in the detection of a specific skin patient and the progress in the control of AT in the middle of the population of the country in general therapists... and cardiologists, who will take care of a single diagnostic and clinical approach. The very tset was looked at as the main thing when preparing recommendations .

Tsilovy Rivn AT

The intensity of the treatment of the ailing hypertension is rich in what should be put in the plan of reducing and reaching the singing level of the arterial grip. With ailments of hypertension, the AT value is less than 140/90 mm Hg. scho є її tsilovim rivnem. In case of hardened portability, therapy dozіlno reduction of arterial grip to more low values. In patients with a high or even high rhizik of the heart-vindicators, it is necessary to reduce the arterial vise to 140/90 mm Hg. і mensh stretching 4 types. Nadal, for clever portability, it is recommended to reduce the arterial vise to 130-139 / 80-89 mm Hg. When carried out antihypertensive therapy Slid mother on uvaz, it is important to reach the level of systolic arterial vise less than 140 mm Hg. in patients with ailments of diabetics, in children with target organisms, in patients with illnesses, and also in heart-and-death acceleration. Reaching the lower end of the arterial vise is less likely with good portability and can take more than an hour, lower than the decrease to a value of less than 140/90 mm Hg. If there is a lack of tolerance, a decrease in the arterial grip is recommended for a decrease in the number of stages. At the cutaneous level of AT, it decreases by 10-15% as of the cutaneous level for 2-4 times. with the onset of a break for the adaptation of the patient to higher low values ​​of AT. The offensive stage of lowering the arterial vise і, apparently, improving the antihypertensive therapy in the case of higher doses, or the number of drugs taken, it is possible only for better tolerance of the same AT values. As soon as I crossed over to the onset of the stage of the wake-up call, I’ll be the patient, docilely turn to the front line for a decade. Thus, the lowering of the arterial clutch to the whole level of arterial pressure is recorded in the number of stages, the number of such individual stages, and the number of such cases, the number of such cases, the number of arterial claws, as well as the tolerance of antihypertensive therapy... Victory of the stage of AT lowering due to the development of individual tolerance, especially in patients with high and even higher risk of acceleration, allowing them to reach the whole level of arterial tension and loss of health When reaching the whole level of the arterial vise, it is necessary to move the lower between the reduction of the systolic arterial vise to 110-115 mm Hg. і diastolic AT up to 70-75 mm Hg. as well as a quest for the team, during the process of not increasing the increase in pulse AT in young patients, which is the leading rank for the reduction of the diastolic AT.

Expertise of all classes of antihypertensive drugs are distributed on the basis of basic drugs (Table 1). The recommendations mean that all the main classes of antihypertensive drugs (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, calcium antagonists, b-blockers), however, reduce arterial pressure; for a skin preparation є bringing the effectiveness and its own counter-indication in singing clinical situations; In most patients with AG, effective control of the arterial vise can be achieved only when combined therapy, and in 15-20% of patients, the control of the arterial grip cannot be achieved by a two-component combination; pre-registration of fixed combination of antihypertensive drugs.

Inadequacies in the management of ailments of hypertension lead to the association of deficiencies with the lack of drugs through the wrong choice of the drug, or the dose, the synergy of the drug becomes apparent in the case of a combination of drugs and problems associated with drug abuse. Yak and kazano, as a combination of drugs, depending on the level of monotherapy in decreased AT.

The assignment of a combination of antihypertensive drugs to all problems can be violated, and that is recommended by authoritative experts in order to optimize the treatment of hypertension. It will be shown in an hour that the combination of drugs is not just overwhelming in the control of the arterial grip, but the prognosis for individuals before the establishment of the hypertension will be reduced, as they will come back to those who have been captured. Oskilki in a drug є a great vibration of antihypertensive combinations (Table 2.), then the main problem of polarization in the vibration of the most beautiful combination with the best evidence for optimal treatment of ailments of hypertension.

In the case of the "Medication therapy" razdilia, it is necessary for all ailments of hypertension to achieve an incremental decrease in AT to the whole level. It is especially safe to reduce AT in children and in sick people, who have suffered an IM and cerebral stroke. Kil-brush characteristic of the preparation lies in the form of cob arterial vise and congenital malaise. For example, in case of hypertension of the 1st stage and in the presence of a high risk, it is more possible to achieve a whole AT on a monotherapy in about 50% of patients. In hypertension of the 2nd and 3rd stages and the presence of factors in a high risk in a large number of cases, a combination of two or three drugs can be known. In this hour, two strategies of starting therapy for hypertension are available: monotherapy and low-dose combined therapy with further reductions in quantity and / or doses of lykarskoe as needed (Scheme 1). Monotherapy at the start of treatment can be used for patients with low or middle risk. The combination of two drugs in low doses can be reduced in ailments with a high or even high rhizik. Monotherapy is based on the idea of ​​an optimal drug for the patient; transition to combined therapy of preschool only in times of daytime to the effect of the rest. Low-to-call combined therapy at the start of the treatment of transferring an effective combination of drugs with developmental mechanisms of action.

Kozhen from tsikh pіdhodіv maє its passages and shortcomings. Perevaga of low-dose monotherapy of polyagi is in that, in the time of the long-term selection of ailments, there is no more than one drug. However, the strategy of monotherapy in the form of a drug addict is optimal for a sick antihypertensive drug with frequent changes in and out of the day, so that it will help the drug and sick child to be successful in success and in the absence of a It is especially important for those suffering from hypertension of the 1st and 2nd stage, most of them do not perceive discomfort due to the development of an arterial grip and are not motivated to addiction.

at combined Therapy in a large number of types of drugs is indicated with different mechanisms for allowing, from one side, to achieve the whole AT, and from the other side - to minimize a number of minor effects. Combined therapy also allows to stifle the counter-regulatory mechanisms of AT adjustment. Stagnation of fixed combinations of antihypertensive drugs in one pill increases the sickness of ailments to addiction. Patients with AT ≥ 160/100 mm Hg May a high and even high risik, dose-based combined therapy may be indicated at the start of the treatment. In 15-20% of patients, the control of AT cannot be achieved with victorian two drugs. At the end of the day, there is a combination of three and more likars' efforts.

As already meant earlier, the order of monotherapy for the control of arterial vise vikoristovuyu combination of two, three and more antihypertensive drugs. Combination moose earlier therapy may be more effective: improving the antihypertensive effect for the development of specific drugs for the pathogenetic mechanisms of the development of AG, which increases the number of patients arising from the stability; A decrease in the incidence of side effects, such as for the reduction of lower doses of combined antihypertensive drugs, as well as for the reduction of mutually neutralization of the effects; securing the most effective organoprotection and reducing the risk of heart disease and the number of heart-vascular acceleration. However, it is necessary to remember that the therapy is combined - a combination of two drug preparations at a minimum, the frequency of which may be different. Otzhe, the consumption of drugs in the combination therapy is guilty of such minds: drugs are responsible for the mother in conjunction with the modalities; we can reach the polypshennya result in case of їх alcohol consumption; drugs for the mother are close to pharmacodynamic and pharmacokinetic indicators, which are especially important for fixed combinations.

The priority of rational combinations of antihypertensive drugs

Experts of RMOAG propose the distribution of a combination of two antihypertensive drugs on rational (effective), possibly and ineffective. American Expert, as in 2010 m presented new algorithm of combined antihypertensive therapy (Table 3), food Practically the same positions. Qia position to become a member of the Duma of European experts on hypertension, caught in the fall of 2009 nourishment Combined therapy and presentation to baby 1.

The Russian recommendations have to admit that, in the world of overvoltage of combined therapy, antihypertensive drugs are used as a combination therapy (Table 2). In the midst of a series of rational combinations for service personnel, special respect for the deyaki, which may not only pass from the theoretical positions of the main mechanism of action, but practically brought high antihypertensive efficacy. In the first place, there is a combination of an ACE Ingibitor with a diuretic, when there are overvolts and shortages. This combination is given to the most popular in hypertension therapy for the establishment of high hypotensive efficacy, for the organisms-targets, good safety and tolerance. In the published recommendations of the American Association of Hypertension (ASH) on combined therapy for hypertension (Table 3), it is also a priority (most of them) to consider a combination of drugs to block the activity of the renin-angiotensinourethyretic systems (blocking of antihypertensive drugs).

Preparations for one at a time in conjunction with a modular addition on the basis of the regulation of the arterial grip and blockade of counter-regulatory mechanisms. Reducing the volume of the circulating age of saluretic diuretic diuretics to stimulate the renin-angiotensin system (RAS), which is the counterpart of the ACE inhibitor. In patients with low activity of renin plasmas of the ACE angibitorium, there is a lack of effective and additional diuretic, which leads to an increase in the activity of the RAS, allowing the ACE angibitor to realize its realization. There are a wide range of ailments that are considered for therapy, and the goals of AT are reached more than 80% of patients. ACE inhibitors prevent hypokalemia and reduce the negative inflow of diuretics to carbohydrate, lipid and purine metabolism.

Angibitories of ACE are widely used in diseases of AH, hospitality of the IXC forms, chronic heart failure. One of the representatives of the great group of Ingibitoriv ACE is lizinopril. The drug is used in detail for vyvcheniya in decilkoh large-scale clinical dosages. Lisinopril has demonstrated prophylactic and therapeutic efficacy in cases of heart failure, including those of severe IM, and in case of adolescent diabetes mellitus (as reported by GISSI 3, ATLAS, CALM, IMPRESS). Among the most clinically diagnosed patients with hypertension in the adult classes of drugs in ALLHAT, lisinopril significantly decreased the incidence of disease on type 2 CD.

The Russian Pharmacoepicidemiological Preceding PIFAGOR III has experienced practical medications for antihypertensive therapy. The results were published in the previous stage until PIFAGOR I in 2002 r. According to the data on the treatment of drugs, the structure of antihypertensive drugs, which are recognized in patients with hypertension in real practice, is represented by five main classes: ACE inhibitors (25%), β-adrenergic blockers (23%), diuretics calcium (18%) and angiotensin receptor blockers. According to the results of the previous PIFAGOR I, there is a decrease in the portion of the ACE inhibitors by 22% and β-blockers by 16%, the decrease in the portion of the antagonists in calcium by 20% and the decrease in the portion of the angiotensin blocker II by 20%, and the decrease in the portion of the angiotensin blocker by 20%, and the decrease in the portion of the angiotensin blocker by 20%, and the decrease in the portion of the angiotensin blocking agent by 20%.

In the structures of drugs in the class of ingibitoriv ACE, the most frequent are enalapril (21%), lisinopril (19%), perindopril (17%), fosinopril (15%) and ramipril (10%). At the same time, in the last few years, there is a tendency towards an increase in the significance and frequency of the use of combined antihypertensive therapy for the achievement of the whole life in patients from AG. According to the data of PIFAGOR III in the period since 2002, the majority (close to 70%) of those who are interested in the more vicious combination of therapy in vigorous children (69%), fixed (43%) monotherapy tactics. Among the combination of antihypertensive drugs, 90% of the drugs are more likely to be diagnosed with antihypertensive drugs with a diuretic, 52% - β-blockers with a diuretic, 50% of drugs indicate that antihypertensives are not calibrated (antihypertensives).

One of the most optimal combinations of an ACE Ingibitor and a diuretic is the drug "Co-Diroton" ® (Gedeon Richter) - a combination of lizinopril (10 and 20 mg) and hydrochlorothiazide (12.5 mg), which is well stocked. "Ko-Diroton" can be victorious in case of the presence of chronic heart failure in a patient with hypertension, severe hypertrophy of the louse, metabolic syndrome, excess oil, sugar diabetes. Chi is justified by the consumption of "Ko-Diroton" in case of refractory hypertension, as well as with a tendency to an increase in the number of hearts.

For the development of a growing interest in drugs before the use of combined therapy, the RMOAG experts presented a table for the first time.

new leader

combined therapy

The combination of calcium antagonist and the ACE Ingibitor in the rest of the rock is gaining more and more popularity, the number of classic viprobans is increasing and the appearance of new combined lykarsk forms. Antagonist of calcium amlodipin bouvie in bagatyokh key projects. The drug is efficiently monitored for AT and is used up to the number of calcium antagonists in the most recent clinical situations. The order of assessing blood pressure-lowering the effects actively evolved vasoprotective and antiatherosclerotic power antagonist of calcium. Bully carried out two additional PREVENT and CAMELOT on the basis of methods used to visualize vertebral disease, in patients with the IXC, in which amlodipine was infused on the development of atherosclerosis. Following the results of the tests and the last monitoring, the experts of the European Association of the AG / European Association of Cardiologists made the recommendations for the manifestation of atherosclerosis of sleepy and coronary arteries in patients with the first Bringing anti-ischemic and anti-atherosclerotic powers to amlodipin is allowed to be recommended for the control of AT in patients with hypertension in the presence of the IXC.

From the point of view of reducing the risk of development of the heart-vascular acceleration and improvement of the prognosis in hypertension (the main meta in the treatment of hypertension), the drug demonstrating a great protective potential in such a predictable, ALL-CUTTING, AS

Clinical practice and the results of decisive clinical trials give vague arguments for the corny of such a combination. The most important in the whole plan were the tributes of such children, such as ASCOT, in which most of the sick were considered to be a combination of antagonist of calcium and angibitor of ACE; recent post-hoc analysis from EUROPA; new analysis of ACTION and especially ACCOMPLISH. In the whole project, the infusion of two modes of cob combined therapy for the frequency of heart-vascular acceleration in 10,700 ailments with hypertension in a high rhizic (60% of patients with hypertension, high diabetes rockiv, the average value of the index of mass tila 31 kg / m2) - the ingibitor of ACE benazepril with amlodipin or thiazide diuretic hydrochlorothiazide.

It is shown that when ailments are transferred to a fixed combination of medical preparations, the control of an arterial grip is rapidly increased, and after three times the diagnosis of a bullet has been recorded rather quickly, some of the bullets have been rejected. With the same control over AT in the whole group, there was a significant decrease in the risk of development of the heart-and-heart acceleration (primary point) in the group, as they considered the combination of the Angiburetic APF by 20%. The results of the last few years are indicative of those that the combination of calcium antagonists with the ACE inhibitors is very promising for greater widespread use in clinical practice. Allowances can be made, such a combination can be especially demanded in the diseases of the AG in the presence of the IXC.

Strengthening blood pressure reduction in case of victorian combination of antagonists of calcium and ingibitoriv ACF supervise changes in the frequency of inconvenient reactions, during the winter of calcification of homilocarbs, characteristic for digestants. Є Dani about those who have a cough, association with the intake of ACE ingibitors, and also relaxed with calcium antagonists, including amlodipine.

Fixed Combinations:

more perevag

For the combined therapy of hypertension, one can choose either a combination of drugs or a fixed combination of drugs. Experts RMOAG recommend to practicing drug users in large numbers of types of drugs for the use of antihypertensive drug combinations, but to put two drugs in one tablet. It is possible to change the value of the fixed combination of blood pressure - to lower the values ​​only in case of absolute ill-health, in the absence of evidence of contraindication to one component. At the documentary it is obvious that the combination is fixed: it will be rational; є the most effective strategy for reaching and adapting the whole level of the arterial grip; I will give you a more beautiful organoprotective effect and reduce the risk of acceleration; Allowing the speed of the number of tablets taken, but also the quickness of the patients in the treatment.

At the same time, in the past, the ACCOMPLISH has been carried out on a consistent basis for the improvement of the efficiency of the fixed combinations. One of the first fixed combinations in our country is the drug "Equator" (in the warehouse there is a calcium antagonist amlodipin and angibitor ACE lizinopril). The offense of drugs may well prove a base, which includes large-scale clinical reports. Clinical presenters demonstrated high antihypertensive efficacy of the drug "Equator". Among the fixed combination drugs in the pre-release PIFAGOR III drugs, 32 commercial names were named, the middle most often referred to the combination of drugs in ACE and diuretics, as well as "Ekvator" in 17%.

Experts are involved in the recognition of a fixed combination of two antihypertensive drugs in the most common treatment of patients with a high heart-blistering rhizic, or just follow the monotherapy.

The role of the largest combinations

in lіkuvanni AG

Prior to any combination of antihypertensive drugs, one should take a second dose of dihydropyridine and non-dihydropyridinic antihypertensive drugs, ACE inhibitors + β-blockers, ARBs + β-blockers, antihypertensive drugs, direct antihypertensive drugs Stagnation of the combination of two-component antihypertensive therapy in the given hour is not absolutely recommended, but it is not hardened. However, it is only permissible to use the vibe against the cinnamon of such a combination of likars' zasob_v only if there is an increase in the ill-health of vicious rational combinations. In practice, we are sick with AH, as there may be IXC and / or a chronic heart failure, at once the ingibitoria of ACE and β-blockers are recognized. However, as a rule, in such situations, the sign of β-blockers is seen as a head rank through the manifestation of IXC or heart failure, so that it is shown by itself (Table 5).

Prior kombіnatsіyam neratsіonalnim at vikoristannі yakih not vіdbuvaєtsya potentsіyuvannya antigіpertenzivnogo efekta preparatіv i / abo posilyuyutsya pobіchnі efekta at їh spіlnomu zastosuvannі, vіdnosyatsya: poєdnannya rіznih lіkarskih zasobіv scho vіdnosyatsya to one Klas antigіpertenzivnih preparatіv, β-blockers + nedіgіdropіrіdіnovih antagonіst kaltsіyu, іngіbіtor ACE + potassium-sparing diuretic, β-blocker + central drug.

nourishment Combination of three or more drugs is still not possible to achieve vaccinations, there are few results in randomized control of clinical patients who were injected with a combination of antihypertensive drugs. In such a rank, antihypertensive drugs in these combinations are based on a theoretical basis. However, for patients with refractory hypertension, including those with refractory hypertension, only three or more component antihypertensive therapy can reach the whole level of AT.

visnovok

New recommendations from Likuvannya AG RMOAG / VNOK especially respect nourishment Combined therapy as the most important component of success in heart-to-heart acceleration. Both the increased interest in combined therapy of hypertension, the number of clinical reports, and the smarter - the best results, and all the different things mean an important tendency in cardiology: an emphasis on the development of high-quality pharmaceuticals. Among the fixed drug forms, experts see combinations of drugs that block the activity of the RAAS (angibitorium ACE and IN.), With calcium antagonists or diuretics.

literature

1. Russian medical partnership on arterial arterial hypertension... Russian recommendations (third revision). Cardiovascular Therapy and Prevention 2008; No. 6, supplement 2.

2. The Task Force for the management of arterial hypertension of the European Society of Hypertension and of the European Society of Cardiology. 2007 Guidelines for the management of arterial hypertension. J Hypertens 2007, 25: 1105-1187.

3. Russian medical partnership for arterial Hypertonia (RMOAG), All-Russian Science Association of Cardiologists (VNOK). Diagnostics and treatment arterial hypertension... Russian recommendations (quarterly revision), 2010.

4. Mancia G. Laurent S. Agabiti-Rosei E. et al. Reappraisal of European guidelines on hypertension management: a European Society of Hypertension Task Force document. J Hypertension 2009 to rock; 27: 2121-2158.

5. Gradman A.H. Basile J.N. Carter B.L. et al. Combination therapy in hypertension. J Am Soc Hypertens 2010 rock; 4: 42-50.

6. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic: the Antihypertensive and Lipid Lowering treatment to prevent Heart Attack Trial (ALLHAT). JAMA, 2002; 288: 2981-97.

7. Leonova M.V. Bulousov D.Yu. Steinberg L.L. analytic group of PІFAGOR. Analysis of the practice of antihypertensive therapy in Russia (as per data from PIFAGOR III). Pharmateca 2009, No. 12: 98-103.

8. Leonova M.V. Bulousov D.Yu. analytic group of PІFAGOR. First Russian pharmacoepidemiologicheskie prelude arterial hypertension. Yakisna klinichna practice, 2002. No. 3: 47-53.

9. Pitt B. Byington R.P. Furberg C.D. et al. Effect of amlodipine on the progression of atherosclerosis and the occurrence of clinical events. PREVENT Investigators. Circulation 2000, 102: 1503-1510.

10. Nissen S.E. Tuzcu E.M. Libby P. et al. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. JAMA, 2004; 292: 2217-2225.

11. Julius S. Kjeldsen S.E. Weber M. et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipin: the VALUE randomized trial. Lancet, 2004; 363: 2021-2031.

12. Dahlof B. Sever P.S. Poulter N.R. et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomized controlled trial. Lancet 2005,366: 895-906.

13. Jamerson K.A. Weber M.A. Bakris G.L. et al. on behalf of the ACCOMPLISH investigators. Benazepril plus amlodipine or hydrochlorotiazide for hypertension in high-risk patients. N Engl J Med, 2008; 359: 2417-2428.

14. Bertrand M.E. Ferrari R. Remme W.J. et al. Clinical synergy of perindopril and calcium-channel blocker in the prevention of cardiac events and mortality in patients with coronary artery disease. Post hoc analysis of the EUROPA study. Am Heart J 2010; 159: 795-802.

15. Elliott H.L. Meredith P.A. Preferential benefits of nifedipine GITS in systolic hypertension and in combination with RAS blockade: further analysis of the `ACTION` database in patients with angina. J Human Hypertension, 25 Feb. 2010 rock; doi: 10.1038 / jhh.2010.19.

Novel Russian Recommendations on Arterial Hypertension - Priority for Combination Therapy (Russian Medical Society on Arterial Hypertension, Section of Evidence Based Hypertensiology)

At the time of the release in 2008 of the third version of the Russian Recommendations on Arterial Hypertension (AH), there will be no new data, which will make it necessary to look at the main document. From the Initiatives of the Russian Medical Association for the AG (RMOAG) and the All-Russian Scientific Association of Cardiologists (VNOK) the results of the great Russian traditions of the problems of hypertension.

Even earlier, the main meta-lykuvannya of ailments of AG polyagaє in the maximum reduction in risk of development of heart-vascular acceleration (SSO) and deaths from them. For dosyagnennya tsієї methylene potrіbnі not tіlki znizhennya AT to tsіlovogo rіvnya, ale i korektsіya vsіh modifіkuyutsya faktorіv riziku, Poperedjennia i upovіlnennya rate progresuvannya i / abo zmenshennya urazhennya organіv-mіsheney and takozh lіkuvannya asotsіyovanih i suputnіh zahvoryuvan - іshemіchnoї hvorobi sericite, tsukrovogo dіabetu ( SD) і etc. In case of ailments, AG AT is guilty of being less than 140/90 mm Hg. scho є yogo tsilovim rivnem.

In addition to monotherapy in hypertensive treatment, there is a combination of 2, 3 and more antihypertensive drugs. In the last few years, the trend towards an increase in the significance of the frequency of combined antihypertensive therapy for antihypertensive treatment is being promoted. Combined therapy is very effective: improving the antihypertensive effect for the antihypertensive effect of developing drugs on the pathogenetic Lanka of hypertension, which increases the number of patients due to stable reduction of arteries. When combined therapy in a large number of drugs are prescribed with different mechanisms for allowing, from one side, the whole level of arterial vise is sought, and from the bottom, the number of fatal effects is minimized. Combined therapy also allows to stifle the counter-regulatory mechanisms of AT adjustment. Stagnation of fixed combinations of antihypertensive drugs in one pill increases the sickness of ailments to addiction.

Combinations of 2 antihypertensive drugs used for rational (effective), possibly and non-rational. All the trials of the combined therapy of targeted only rational combinations of antihypertensive drugs. Before them, the ingibitor of the angiotensin converting enzyme (ACE) + diuretic is introduced; angiotensin II receptor blocker (ARB) + diuretic; angibitor ACE + calcium antagonist; ARRA + AK; dihydropyridine calcium antagonist + β-blocker; calcium antagonist + diuretic; β-blocker + diuretic.

One of the most effective ones is the combination of ACE Ingibitors and Diuretics. Shown before the stasis of the combination - diabetic and non-diabetic nephropathy; microalbuminuria (MAU); hypertrophy of the lilac duck; SD; metabolic syndrome (MS); abduction of vіk; Systolic hypertension is isolated. The combination of antihypertensive drugs in various classes є one of the most frequently recognized, one of them - the combination of perindopril with indapamid (NOLIPREL A and NOLIPREL A forular) for the last day

New combined therapy of AG (fixed combination therapy)

Earlier, I heard about the emergence of a new salt of perindopril arginine, which I called "pretarium A", instead of tertbutylamine salt. In addition to the new proponents of NOLIPREL A, in which arginine sil perindopril in a dose of 2.5 and 5 mg is presented in a combination with indapamid 0.625 (NOLIPREL A) and 1.25 mg (NOLIPREL A forte) apparently.

Effectiveness of Nolіprela Bula vivchen in bagatokh international and Russian clientele preschool. One of them is the Russian program STRATEGY (a comparative program for evaluating the effectiveness of Noliprela in patients with arterial hypertension and lack of control of the arterial grip). At the same time, the effectiveness of the fixed combination of perindopril / indapamid (Noliprela and Noliprela forte) in 1726 ailments of hypertension with insufficient AT control has been observed.

In the course of the OPTIMAX II release, the injection of MS was introduced according to the NCEP ATPIII criteria for the control of AT in patients with hypertension, who would be able to obtain NOLIPREL. In the case of prospectively, the triviality of 6 m / s buli included 24,069 ailments (56% of choloviks, middle age 62, 18% had SD, middle AT with 162/93 mm Hg MS included in 30.4%). The frequency of normalization of the arterial grip was reduced from 64 to 70%, depending on the mode of recognition of Noliprela forte - as a pochatkova therapy, instead of a supplementary therapy, and did not lie in the presence of MS.

Adequate control over the level of the arterial grip for the additional combined drug NOLIPREL A forte will provide organoprotection. It is shown in the preliminarily PICXEL that the fixation of the fixed combination of Noliprel forte is more effective in reducing the hypertrophy of the louse, rather than monotherapy with high doses of the therapy for the control of the APF. Tse bulo persche dlіdzhennya, in which vyvchavya infusion on the hypertrophies of myocardiums of the combined preparation in the form of starting therapy.

According to the data of the PREMIER (Preterax in Albuminuria Regression), NOLIPREL forte large world, nizh enalapril at a high dose of 40 mg, changing the incidence of albuminuria in patients with CD of the 2nd type, in case of arterial hypertension. In the case of a whole controlled patient, he took the fate of 481 ailments from type 2 CD, AG and MAU. Chvor buli were randomized in 2 groups, when they were treated with a combination of perindopril 2 mg / indapamid 0.625 mg (up to 8 mg or 2.5 mg separately), or enalapril 10 mg (supplemented up to 40 mg) if necessary.

Stagnation of fixed combination of NOLIPREL forte in patients with type 2 CD in pre-ADVANCE (Action in Diabetes and VAscular disease - preterax and Diamicron MR Controlled Evaluation) significantly reduced the risk of development of the main CVD deaths, including In the doslіdzhennya bouly 11,140 ailments were included with the type 2 CD, and the development of accelerated development with a high rhizik. In the course of a trivial sparing (in the middle 4.3 rock), the emergence of the main macro- and micro-vascular depressions (the primary point) significantly decreased by 9% (p = 0.04). Likuvannya Noliprel in ailments on type 2 CD caused a significant decrease in the risk of death from all causes by 14% (p = 0.03) and from cardiac causes by 18% (p = 0.03). In the group of active treatment, the development of coronary arteries was significantly reduced by 14% (p = 0.02) and by 21% (p 140 mm Hg and / or diastolic AT (DAP)> 95 mm Hg). antihypertensive therapy, when included in the program, is represented by β-adrenergic blockers, AK, ACE inhibitors (antihypertensive therapy), diuretics (cry arifon, indapamid), central therapy drugs, antihypertensive drugs and antihypertensive drugs. in the pre-disease period, a combination of perindopril arginin / indapamid was prescribed. івні SBP ≥130 mm Hg or / abo DAP ≥80 mm Hg the dose of Nolіprel A forte was podvoyuvali (2 tablets for dobu).

The twelve-week period of active caution was completed by 2296 ailments of AH with a high and even high risk of development of SSO (31% of men and 69% of females) at 57.1 per cent. Pochatkovo klinichne AT deposited 159.6 / 95.5 mm Hg. After 4 months, the decrease in SBP to 135 mm Hg was significantly and clinically significant. (R

Hypertensive ailments and arterial hypertension are significant changes in the condition of an insult, an infarction, a vermin ailment and chronic ailments nirok. Through incapacitation, mortality and vitrate for the suspension of the prevention and treatment of hypertension as an important problem of the community's protection of health. Happily, the end of the day and the last few days in the hallway have brought up the development of the pathophysiology of hypertension and the formulation of new pharmacological and interventional methods of capturing a wider one.

development mechanisms

It is not clear what the diagnosis of hypertension is. Mechanism and development is very flexible and even foldable. At the same time, they take on the fate of the development of chemistry, judgment of the reactivity and tone, the viscosity of the blood, of the robot of the heart and of the nervous system. The genetic strength is transmitted to the development of hypertensive ailments. One of the current hypotheses is to serve as a statement about immune damage in the body. Immune clientele to feel the organization of the mission (judges, nirks) and victories in the style of destruction of their robots. Tse bulo is indicated, zokrema, in some people with VIL-infectious disease, and in the sick, they took it for a long time to stifle immunity.

With a lot of development, labial arterial hypertension will form. Vona supervise the instability of numbers in the vice, hardened by the robotic heart, and the tone of the judges. Tse persha stage of ailments. In a whole hour, it is not easy to reestablish a diastolic hypertension - to adjust only the lower digits in a vice. Especially often, young women are tied with an overworld body and are tied with a nape of the vertebral column and a peripheral support.

With the help of the year, the grip will become permanent, the aorta, heart, nirks, eyes and brain will be affected. To fix another stage of ailment. The third stage is characterized by the development of an accelerated development from the side of the affected organs - myocardial infarction, nirkovy deficiency, damaged vision, insult and other important camps. To this, there is labial arterial hypertension in the immune system of an early manifestation and treatment.

Progression of hypertensive ailments of the viglyadє call it like this:

• transient arterial hypertension (timchasova, deprived of stress or hormonal coughs) in people of 10-30 years, which is superfluous to the blood of the heart;
• early, often labial arterial hypertension in individuals up to 40 years, in those who already support the blood flow of other vessels;
• ailment for organ target organisms in individuals of 30-50 rocks;
• admission of acceleration at lіtnіkh; at the end of the hour, after suffering an infarction, a weak heart muscle decreases, the robot's heart and heart wikid go down, and the arterial grip does not go down very often - such a state is called “headlessness of the lack of hypertension” and the awareness of the heart.

The growth of ailments is closely tied to hormonal impairments in the body, the first for everything in the "renin - angiotensin - aldosterone" system, which is due to the amount of water in the body and the tone of the sudin.

cause sickness

Essential hypertension, storage of up to 95% of all hypertensives, winery for the inundation of unfriendly factors in conjunction with genetic cravings. However, specific genetic anomalies, attributable to the development of ill health, and did not appear. Evidently, if one gene is damaged in the robot, one gene develops before the development of pathology - the Liddle's syndrome, which causes the type of pathology of the supra-nirkoval hallux.

Secondary arterial hypertension can be a symptom of early illness.

Nirkovy causes storage of up to 6% of all types of hypertension, including reduced tissue (parenchyma) and sudin nirok. Renoparenchymal arterial hypertension can be diagnosed with such ailments:

• polycystosis;
• chronic ailment nirok;
• Liddle's syndrome;
• the suppression of the secular nobles with stone or chubby;
• pukhlina, scho vidіlyaє renin - a hard-hearted, court-sounding rhetoric.

Renovascular hypertension is tied to the lesions of the Sudin, which helps to live the nirkas:

• coarctation of the aorta;
• vasculitis;
• the sound of the nirkovo artery;
• collagenosi.

Endocrine arterial hypertension develop more - up to 2% vypadkiv. The stench can be found in the treatment of certain drugs, for example, anabolic steroids, oral contraceptives, prenizolone or non-steroidal antiapalnic drugs. It is also a vise to promote alcohol, cocaine, coffee, nicotine and preparations of licorice root.

Due to the grip of supravodzhuyutsya a lot of problems with nadnirnikov: pheochromocytoma, improved viroblasting aldosterone and іnshі.

Icnu group of hypertension, tied with cerebral fluff, polyomyelite or a high internal cranial vise.

Nareshti, do not forget about such great reasons for getting sick:

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

Obstructive sleep apnea syndrome is a common cause of obstructive vise. Clinically, it is shown in the periodic zupinka behavior of the chronically through chronically and on the appearance of a re-code in the daily routes. Approximately half of such patients can move in a vice. The elimination of the syndrome allows the normalization of hemodynamic parameters and polypsychiatric prognosis in patients.

Designation and classification

The type of arterial vise is systolic (to develop in the vessels at the time of systole, so that the heart is fast) and diastolic (to get into the vessel bed of the tonus before the hour of myocardial relaxation).

The system of classification is more important for taking decisions about aggressiveness of treatment or therapeutic involvement.

Arterial hypertension - the chain of a vise up to 140/90 mm Hg. Art. and vishche. It is not uncommon to become offended by numbers, but to be called systolic-diastolic hypertension.

In addition, blood pressure with hypertension can be normal in humans, antihypertensive drugs can be gradually taken off. Diagnosis in such a way is obvious from the history of the ailment.

Talk about prehypertonic conditions at a pressure of up to 139/89 mm Hg. Art.

Grade of arterial hypertension:

• persha: up to 159/99 mm Hg. Art.;
• friend: від 160 / від 100 mm Hg. Art.

Such a singing world cleverly, the splinters of one and the same patient in the minds of children are indications of a vice grow.

The classification is based on the middle 2 or a higher value, on the skin 2 or more changes in the first change in the drug. Superbly low showing is also guilty of evaluating from the point of view of clinical significance, even the stench may not only pogirshuvati self-respect of the patient, but I am familiar with serious pathology.

Classification of arterial hypertension: it may be the first one, it developed due to genetic reasons. With a lot of help, the reason for the ailment is to become homeless. Secondary hypertension of viclikan with small illnesses of other organs. Essential (without an apparent reason) arterial hypertension is observed in 95% of all cases in older adults and is called hypertensive ailment. Children have secondary hypertension, which is one sign of being sick.

Arterial hypertension is affected, but it does not give way to likuvannyu, it is not loosely tied itself with an unreported secondary form, for example, with a primordial hyperaldosteronism. The form of diagnostics is uncontrolled, if the combination of three hypotensive medications, including a sechogenic drug, cannot be reached by the norms.

Клінічні signs

Symptoms of arterial hypertension are not very active, so that ailments do not catch any scarg, as long as they do not have a problem with organ targets. In general and in the field, the incidence of ailments, even at the II-III stages, if the heart is already damaged, nirki, brain, very bottom, it is practically uncomfortable to turn back processes.

On what signs it is necessary to brutalize respect and turn up to the likar, or if you want to start working on your own, you need to keep the grip of the additional tonometer and write down self-control in the schoolboy:

• dull beak in half of the breasts;
• breaking the rhythm of the heart;
• b_l in the country;
• periodically zamorochennya і noise from vuhah;
• pogirshennya zoru, singing to the beaches, "fly" in front of the ochima;
• zadishka when navantazhennі;
• cyanosis of the hands and feet;
• swelling or swelling;
• attack the breath or coughing up blood.

An important part of the fight against hypertension is free of charge for the medical examination, as a skin person can go through his clinic without any problems. Also, throughout the country, the health center, de likari tell about the illness and carry out the first diagnostics.

Hypertensive crisis and a thirsty person

With a hypertensive crisis, the grip increases to 190/110 mm Hg. Art. and more. Such arterial hypertension can be reduced to the reduction of internal organs and development:

• neurological: hypertensive encephalopathy, cerebral vertebral disasters, cerebral infarction, subarachnoid hemorrhage, intracranial hemorrhage;
• heart-sore throat: myocardial ischemia / infarction, gostry nabryak legeniv, aortic enlargement, unstable angina pectoris;
• іnshі: gosstra nirkov deficiency, retinopathy with the second zoru, eclampsia in vaginal patients, microangiopathic hemolytic anemia.

Hypertensive crisis of non-secret medical aid.

Gestational hypertension is a part of the so-called OPG-gestosis. I don't want to go to the lykar for help, the powerful development of the preclamps and eclamps - will become, so to clutter up the life of the mother and the fetus.

diagnosis

Diagnosis of arterial hypertension in general includes more precisely the reduction of the patient's grip, the rectification of the patient's anamnesis, the background and rejection of laboratory and instrumental data, including 12-channel The timing is necessary for the designation of the offensive positions:

• urazhennya organ_v-targets (heart, brain, nirki, eyes);
• imovirni causes of hypertension;
• specific indicators for a further assessment of biochemical therapy effects.

At the presentation of a singing clinical picture, if there is a suspicion of secondary hypertension, it is possible to carry out the second preliminaries - a level of sechaic acid in the blood, microalbuminuria (block in the section).

• echocardiography for the designation of the heart;
• ultrasound monitoring of internal organs for the diagnosis of nirok and supra-nirkoval villosis;
• tetrapolar rheography for the type of hemodynamics (as a rule of thumb);
• monitoring the grip in the outpatient minds for the clarification of the number in the day and night;
• Dobové monitored by electrocardiographers, given no sleep apnea.

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

Likuvannya of arterial hypertension in the capacity of the first croc to transfer to the Korean way of life.

Way of life

It is possible to change the vice і risiku for the heart if we do it at least 2 with the following rules:

• decrease in mass (with a consumption of 10 kg, the vice will decrease by 5 - 20 mm Hg);
• reduction in the consumption of alcoholic beverages to 30 mg of ethanol for people and 15 mg of ethanol for women with normal vogue per day;
• salt intake is not more than 6 grams per day;
• sufficient reliable calories, calcium and magnesium from the hedgehog;
• vidmova vid kurinnya;
• reduction in the implantation of saturated fat (tobto solid, food) and cholesterol;
• aerobno navantazhennya stretching p_vgodini a day is practically every day.

Drug treatment

As a matter of fact, arterial hypertension can be taken care of at all visits, as well as a variety of options for drug therapy. When out of the day, a contraindication and only after consultation with a drug, the first row is called a diuretic. It is necessary to remember that self-indulgence can be victorious against negative inheritances in ailments with hypertension.

Yakshko є risik, or even more rozvinenno dodatkovo stan, in the scheme of treatment include the following components: ІАПФ (enalapril and іnshі), calcium antagonists, beta-blockers, blockers of receptors to angiotensin, antagonism of alimentary action. Pidbir therapy is carried out on an outpatient basis for a trivial hour, until the combination is optimal for the patient. You will need to be victorious after all.

Information for patients

Hypertonia is a disease for all life. Pozbutisya vid nogo unhappily, behind a vignette of secondary hypertension. For optimal control over ailments, it is necessary to keep the robot on itself and take medication. The patient is guilty of the "School for the ailing with arterial hypertension"

She is guilty of the nobility and the viconuvati patient with hypertension:

• to adjust the normal way and the circumference of the body;
• gradually take care of physical rights;
• live less salt, fat and cholesterol;
• live more minerals, zokrem, kaliyu, magnesium, calcium;
• obmezhiti vzhivannya spirits;
• іdmovitsya vіd kurіnnya і implantation of psychostimulant speeches.

Regular control of the grip, the introduction of the drug and the correction of behavior, help the sick person with hypertensive ailment to reduce the visibility of life through a stretch of rock.

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Features of hypertension 3 steps

1. Also 3 steps of hypertensive ailment
2. A group of patients with hypertensive ailments
3. symptoms
4. To uvagu brutal
5. Reasons for the development of hypertension stage 3

Hypertonic ailment - the problem is broadened. The most unsafe option is at least 3 steps of this disease, protest, when diagnosing a diagnosis, include the stage and steps of the disease.

People, who may be in the middle of an arterial grip, are guilty of rosum, which will block them, so that they can always live adequate calls and do not do it well, and without that, a high risk of development is slowed down. For example, how does it cost to diagnose hypertonic ailment rhizik 3, how can it be, how do these numbers mean?

The stench means that in people with such a diagnosis, the risk of otrimati through hypertension becomes 20 to 30%. When the indicator is overridden, a diagnosis of hypertension of the 3rd stage, rhizic 4. An offense to the diagnosis means the need for term new entry from the disease.

Also 3 steps of hypertensive ailment

Dana steps are taken to get involved in importance. It starts with AT indicators, like this:

• Systolic vise 180 і more mm Hg;
• Diastolic - 110 mm Hg and vishche.

Rivn AT with a large number of changes and may gradually disappear at the views, which are critical.

A group of patients with hypertensive ailments

In total, there are 4 such groups in the fallowness of the heart, the heart, and of the other organ-targets, as well as the manifestation of the tension factors:

• 1 risik - less than 15%, no heavy factors;
• 2 risik - from 15 to 20%, heavy factors not more than three;
• 3 risik - 20-30%, more than three tight factors;
• 4 risik - vishche 30%, heavy factors more than three, є chopping of organ-targets.

Up to the factors of tightness, lack of physical strength, lack of physical support, occupation of a vag, a camp of chronic stress, inadequate harassment, diabetes, endocrine disruption.

With a hypertension of 3 steps with a risik 3, there is a threat to health. Most of the patients are in 4 groups. A high risik is energetic and with higher low AT values, as well as an individual skin organism and a large reserve of nutritional value.

The last step and the group of patients begin the next stage of hypertensive ailments:

• 1-zmіna і pozhkojen in organs-targets is not;
• 2 - changes in decorative target organs;
• 3 - environment of target organ strike plus acceleration: infarction, stroke.

symptoms

With the development of hypertension up to 3 steps with rhizics 3 and 4, do not cure the symptoms, it’s uncomfortable for the stench to come through. The main symptom is the critical signs of an arterial vise, as well as ailments.

You can show:

• Lost and headaches with pulsation;
• Migotinnya "fly" in front of the eye;
• I will be buried in the headquarters;
• Weakness in the hands and feet;
• Problems with dawn.

Why are these symptoms diagnosed? The main problem with hypertension is the tse of fabrication of fabrics. Visoké AT zbіlshu navantazhennya to the shipwreck.

The inner ball is in the air, and the ball of the Sudin is filled with sound, through which it sounds. For reasons of judgment, it is not so elastic, cholesterol plaques set in on their walls, the judgment of the judgment will sound even more, and blood circulation becomes more difficult.

In general, the risk for health is even great, and the hypertension of the 3 steps with the risk of the 3 will block the entire process. Organizational targets are especially concerned:

• heart;
• nirki;
• Brain;
• The link of the eye.

See you in the heart

Livy duck heart expands, growths of a ball of myazovyh in its walls, buried elastic power of the myocardium. By the end of the day, the lіviy slunchok is not in the snake to cope with its functions, but it will clog up the development of the heart failure, as if it doesn’t survive the adequate calls.

nirok battle

Nirki is a tse organ, which is clearly taken care of with blood, so the stench often suffers from a forced vice. The smashing of the nyrcovs' vessels was destroyed by blood.

The result is an old chronic nirkova lack, so as ruinous processes in vessels produce up to changes in tissues, which cause damage to the function of the organ. Exercise nirok is possible with hypertension stage 2 3 stages of risk 3.

In case of hypertensive ailments, there is a bleeding disorder of the suffering and the brain. The price is overwhelmed by sclerosis and a decrease in the tone of the sudins, the brain itself, as well as the arteries, scho to pass the bridle of the ridge.

The situation is slowed down, like the judgment of the patient is very twisted, but it is not easy for the patient to go to the organisms, as well as the vivacity of the patient's thrombosis. As a result, in case of hypertensive ailments without timely adequate assistance, the brain is inadequate and inappropriate.

The child's memory will go down, respect will go down. A moody development of encephalopathy, which is supervised to reduce the intellect. Even if there is no trace of inheritance, the stench can be produced to the point of being lost.

Confirmation of blood clots in the vessels, which can lead to the brain, increases the amount of ischemic insult, and the formation of a blood clot can lead to hemorrhagic insult. The traces of such stuns can be disastrous for the body.

Injection to the organization

In a part of the ailments on hypertonic ailment 3 steps with 3 steps the rhizik will see the battle of the eyes of the eye. It is negative to be recognized in the state of the art, it can be lowered, so it is possible to flash a fly in front of the ochima. For an hour, Lyudin sees a grip on an apple, in such a state of mind, he gradually sees drowsiness, and the state of affairs decreases.

More than one nebezpeka - bloodshed

One of the most dreadful slowing down of hypertension is 3 steps with a rhizik 3 - bloodshed in the organism. There are two reasons for this.

1. In a persistent way, make the walls of the court on the floor draw in elasticity, so they become brittle.
2. On the other hand, bloodshed is possible on the site of aneurysms, which is why here the walls of the vermilion appear to groan and tear easily.

A small amount of bleeding as a result of the formation of a rupture or aneurysms can lead to the formation of hematomas, in the case of great growths of hematomas, it can be large-scale and pozhkozhuvati internal organisms. There may also be severe bleeding, for the soreness of which a term is needed, medical additional help is needed.

If you think so, the grip of a person immediately sees, however, the process is far from expected. The skin has an individual threshold of sensitivity.

The most common option for the development of hypertensive ailments is the duration of symptoms before the onset of a hypertensive crisis. This also means the manifestation of hypertension of the 2nd stage of the 3rd stage, so I will be able to tell you about the destruction of organs.

The period of asymptomatic interruption of the disease can be trivial. If a hypertensive crisis does not occur, then the first symptoms appear step by step, on which patients are often not beastly, they write off everything on the same stress. Such a period can be easily carried over to the development of arterial hypertension of the 2nd stage with a riser 3.

To uvagu brutal

• Regular mischief and headaches;
• Feel the health in the area, reduce the hardness in the head;
• Noise in the Vukh;
• "Flies" in front of the ochima;
• Zagalne tonus reduction4
• Ruined sleep.

If I don’t have a lot of respect for the symptoms, then the process is far away, and there is no way to move on to the judgment, the stench is getting better at coping with the robot, the riziki grow up. Ailments go into the onset stage and the onset of the steps. Arterial hypertension 3 steps Rizik 3 can progress even more quickly.

As a result, there are more serious symptoms:

• gratitude;
• Decreased memory;
• Zadishka with a small physical navantazhennі;
• Destroyed Zoru;
• Interruptions in the robotic heart.

In case of hypertension of 3 steps of risk 3, the rate of disability is great through a large-scale development of the Sudin.

Reasons for the development of hypertension stage 3

The main reason why I’ll see a greater development of such an important stand, as hypertonic ailment of the 3rd stage, is due to the lack of therapy or lack of therapy. It can also be seen, as the blame for the drug, and the patient himself.

If there is a lack of information, or if it is disrespectful and has broken an inappropriate scheme of treatment, then the arterial grip and repair processes will not be reduced. The same is the problem of pedagogues of patients, which is unimportant to put to oneself and not to see the attributions of fahivts.

For correct diagnostics, an even more important anamnesis, so that information, is taken out for an hour, knowing the documents and from the sick person. Vrahovyatsya skargi, indicators of arterial grip, the appearance of acceleration. Vimiryuvati arterial vise is required regularly.

To make a diagnosis of a drug, it is necessary to give a dynamic warning. For the whole, it is necessary to have an indicator of two per day stretching two times. Dani vimiryuvan arterial vise allows to assess the country of the Sudin.

Інші diagnostics come in

• Listening to the lungs and heart tones;
• Percussion of the vessel bundle;
• Setting the configuration of the heart;
• electrocardiogram;
• Ultrasonic examination of the heart, nirok and other organs.

To clarify the body, it is necessary for the body to analyze:

• Instead of glucose in blood plasma;
• Zagalny analysis of blood and slaughter;
• Riv to creatine, sech acid, calories;
• Viznachennya klіrence creatine.

In addition, a car can indicate additional conditions that are necessary for a particular patient. In patients with hypertension, stage 3, 3 stages of risk, there are 3 presence of additional tight-knit officials, who are more respected.

Lykuvannya hypertensive ailments 3 stages risik 3 maє on uvazi complex of visits, which includes lykarsk therapy, child and active way of life. Obov'yazkovoyu є vidma from shkidlivyh calls - kurinnya and implantation to alcohol. It is a factor that means to lose weight of the Sudin and to increase the weight of the rhiziki.

For the therapy of hypertension with rysics 3 and 4, there will be little drug treatment with one drug. A combination of drugs is required to be included in the development group.

To ensure the stability of the arterial vise indicators, it is recognized in the main prolonged preparation, which lasts up to 24 years. The preparation of drugs for the treatment of hypertension of the 3rd stage is healthy, not only because of the symptoms of an arterial grip, but rather early and early onset. Prescribed drugs are not guilty of the mother of side effects not appropriate for a particular patient.

Main groups of drugs

• sechogіnnі;
• Іngіbіtori APF;
• β-adrenergic blockers;
• Calcium channel blockers;
• AT receptor blockers 2.

In addition to drug therapy, it is necessary to take care of the mode of eating, right and wrong, give them the best possible options. Likewise results cannot be seen at once. It took a trivial hour to get help for the symptoms.

In case of hypertensive ailment, the part of the disease is important.

Bring the products to the test, as they consume the grip and accumulate cholesterol in the vessels.

Vzhivannya salt needs to be brought to the very minimum, in an ideal, no more than half a teaspoon for doba.

fence products

• smoked meats;
• salt;
• Gostrі stravi;
• Kava;
• napivfabrikati;
• Mint tea.

Increase in arterial hypertension of the 3rd stage of rhizic 3 is uncomfortable, it is not really a matter of ruinous processes and additional assistance to the organism to become aware. The triviality of the life of patients with hypertonicity 3 worlds to lay down on the steps of the development of ailments, freedom and quality of treatment and attention to the patient's recommendations.