Hypertension (9) – Abstract , page 6


Treatment of hypertension in special
groups and situations



AG
in the elderly and isolated
systolic hypertension.
Modern
recommendations consider systolic
HELL along with the diastolic as
the criterion for diagnosis, severity
and efficacy of antihypertensive
therapy. The decrease in systolic BP
leads to a distinct reduction of this
risk. Thus, in the elderly
systolic blood pressure allows better
to predict the risk of complications than
the diastolic blood pressure. It was recently
it is established that even more important
has a high pulse pressure.
Proven antihypertensive
therapy to at least 80 years
age. However, if regular treatment
AG started early, it should continue
and even older. In the presence of
AH at the age of 80 years, the decision
necessary care are based on
the specific clinical situation.
In the diagnosis of hypertension should be
keep in mind that the elderly can
to identify about the AD
(“pseudohypertrophy”) as a result
increase the stiffness of blood vessels. In addition
moreover, elderly patients often
“white coat hypertension”,
postprandial and orthostatic
hypotension. If the blood pressure starts to rise
after age 60 or is resistant to treatment,
it is necessary to exclude secondary
hypertension, primarily associated
with atherosclerotic stenosis of renal
artery.



Treatment
Hypertension in the elderly, including isolated
systolic,
leads
to a significant decrease in the frequency of stroke,
Coronary artery disease, heart failure and
mortality. Therapy is advisable
start with lower doses of antihypertensive
drugs. Preferably
diuretics. The alternative is
long-acting digidropiridinovmi
calcium antagonists. Grounds for
consideration of hypertension in the elderly, including
isolated systolic hypertension separately
primary hypertension has no. The reason
in the proven efficiency of treatment in
this group in reducing risk
cardiovascular complications according to
least to the same extent that
patients of middle age. Treatment
Hypertension, including isolated systolic,
elderly patients should start
with non-drug measures
to limit the intake of salt and reduce
of body weight. If not achieved the desired
the decrease in blood pressure, shown medical
treatment. Initial doses of antihypertensive
drugs in the treatment of elderly needs
to be less than half of patients
young and middle-aged. Recommended
begin treatment with diuretics because of their
proven impact on morbidity
and mortality in the elderly.
Given the clinical features of AH in
elderly people, the caution should be
to use drugs that can cause
orthostatic hypotension (a-adrenergic blockers)
and cognitive dysfunction
(Central a2-adrenergic
agonists). Target blood pressure in elderly
patients is the same as in young,
however, in cases of severe, long-term
untreated systolic hypertension
enough to reduce systolic blood pressure
to 160 mm Hg. article



Of hypertension in women



AG,
associated with oral
contraceptives.
Welcome
oral contraceptives leads to
a small rise in blood pressure, usually in
the range of normal values. However
women taking oral
contraceptives, hypertension occurs two to three
times more likely compared to women not
are taking these drugs. Additional
risk factors for hypertension are age >
35 years, obesity, Smoking. If a woman
can’t give up Smoking, you should
to recommend the discontinuation
oral contraceptives. In most
cases AD normalization notes
a few months after the abolition of
drugs. If you kept increasing
HELL, and risk the consequences of a possible
pregnancy outweighs the risk of consequences
AH, the possible continuation of the oral
contraceptives and the appointment of
antihypertensive therapy. When you receive
oral contraceptives HELL appropriate
monitor every 6 months.



AG
during pregnancy.
AG
occurs in 8 -10% of pregnant women and is
one of the main causes of complications in
mother and fetus that determines the specific
the importance of adequate blood pressure control in
pregnancy. When diagnosing hypertension
in pregnant women it should be borne in mind that
in the first half of pregnancy HELL
reduced. This trend continues
and in women with prior hypertension. When
normal pregnancy amount
circulating blood (a physiological
hypervolemia), and in pregnant women with hypertension, he
reduced, which can lead to violation
perfusion of the placenta. Hypertension in pregnancy
may be a continuation of the chronic
disease (essential or secondary
hypertension) or occur for the first time on
late pregnancy (gestational
hypertension or preeclampsia). Possible
a combination of both. HELL >170/110 mm Hg. the article is
a commonly accepted measure of significant
the risk of stroke or eclampsia.
The appropriateness of therapy with a more
low blood pressure remains controversial. Increase
HELL >150/100 mm Hg. art is the basis
for hospitalization. During pregnancy
safe use of methyldopa,
nifedipine (preferably prolonged
forms), gidralazina and labetalol.
-Blockers
(atenolol, metoprolol) effective and
safe for use in the third trimester
pregnancy. Earlier
-blockers
can cause growth retardation of the fetus. For
relief of hypertensive crises
appropriate intravenous use
magnesium sulfate, gidralazina or
of labetalol. Diuretics used
limited due to fears of lower
the volume of circulating fluid, do not
it is recommended that their use in
of pre-eclampsia. During pregnancy
contraindicated ACE inhibitors and
blockers of receptors of angiotensin II,
which can cause fetal death and
give a teratogenic effect.



AG in
postmenopausal women. Hormone replacement
therapy.
Large
randomized controlled
studies have not revealed any dependencies
efficacy and tolerability
antihypertensive drugs the main
classes from the floor. The available data
indicate intersexual differences
hemodynamic parameters of patients
essential hypertension: in women
higher heart rate in
rest, cardiac index and pulse HELL
lower total peripheral resistance
vessels. Women have less myocardial mass
the left ventricle at any level of HELL
however, these differences disappear after
menopause. In addition, women frequently
revealed “white coat hypertension”,
high blood pressure variability. Women
postmenopausal women represent
a high risk category of developing hypertension
and coronary artery disease. Menopause is accompanied by
increased levels of LDL cholesterol and
decrease cholesterol HDL. This
category of women is more common
hypertriglyceridemia, impaired
tolerance to carbohydrates, changes
of hemostasis with the increase
activity coagulation. Such factors
the risk of coronary heart disease, like diabetes, reduced
of HDL cholesterol, hypertriglyceridemia
women in menopause have a greater
value than men. The presence of hypertension is not
is a contraindication to the appointment
hormone replacement therapy, which
no significant impact on
blood pressure and can improve overall profile
cardiovascular risk factors.



AG
and cerebrovascular disease.
AG
leads to significant changes
structure and function of the vascular system
the brain and contributes significantly
contribution to the development of chronic forms
cerebrovascular insufficiency,
hemorrhagic and ischemic
strokes. Patients with acute violations
cerebral circulation (stroke,
transient ischemic attack) are
emergency hospitalization in
specialized departments. When
the presence of hemorrhagic stroke by
the background of the high BP values is recommended
a rapid decrease of its level by 25-30%.



When
acute ischemic stroke
is recommended
temporary withdrawal of antihypertensive
therapy to stabilize the condition
patient. However, blood pressure should
be carefully monitored, especially
if the patient receives fibrinolytic
therapy. If systolic BP >180 mm
RT. art. or diastolic blood pressure>105 mm Hg.
article shown intravenous
antihypertensive drugs under
careful control of neurological
symptoms. Antihypertensive
therapy after a stroke
should be aimed at achieving
target BP levels, but without orthostatic
hypotension and the appearance and/or worsening
symptoms of regional failure
circulation. Achievement of target
pressure in this group is of particular
the value in terms of prevention
cerebrovascular and cardiovascular
complications. A reduction in the frequency
strokes when applying -blockers,
diuretics and calcium antagonists
digidropiridinovmi series. Patients
with a history of indication of the transferred
a stroke or transient ischemic
attack, have an increased risk of developing
repeated cerebral and/or
cardiovascular complications. When
this risk is directly proportional
level of HELL. There is evidence of positive
the influence of calcium antagonists, inhibitors
ACE on cerebral blood flow,
structural changes of cerebral vessels
of the brain.



AG
and left ventricular hypertrophy.
Hypertrophy
the left ventricle is strong
independent risk factor for sudden
death, myocardial infarction, stroke, and
other cardiovascular complications.
Studies suggest
on the possibility of reducing the mass of the myocardium
the left ventricle and reducing the thickness
its walls in patients receiving antihypertensive
drugs (with the exception of direct
vasodilators gidralazina and
Minoxidil), weight reduction and limitations
salt intake. Regression
electrocardiographic signs
left ventricular hypertrophy is associated
with reduced risk of cardiovascular
complications. ECG remains the most
available method for the diagnosis of hypertrophy
the left atrium and left ventricle
detection of myocardial ischemia and violations
rhythm. Echocardiography is the most
specific and sensitive method
detection of left ventricular hypertrophy,
but quite expensive for a wide
use.



AG
and coronary heart disease.
The presence of
Coronary artery disease in a patient with arterial hypertension testifies
very high risk of cardiovascular
complications, which are directly proportional
level of HELL. It is established that -blockers
in patients undergoing myocardial infarction,
approximately 25% reduce the risk
re-infarction and cardiac death.
Presumably the risk of recurrent
complications are decreased when applying
verapamil and diltiazem after suffering
myocardial infarction without the Q wave and
preserved left ventricular function.
The use of short-range
antagonists of calcium increases the risk
of recurrent complications. Patients
heart failure and
left ventricular dysfunction is established
reducing the risk of heart attack
myocardium and sudden death, approximately
20% when using ACE inhibitors.
There is evidence of additional
cardioprotective properties
-blockers
and ACE inhibitors in this group of patients
which cannot be explained only by the decrease
HELL.



Aspirin
and AG.
In
study NOTES (Hypertension Optimal Treatment
optimal treatment of hypertension) proven
reducing the risk of myocardial infarction in
15% of patients with well-controlled hypertension
with daily admission
75 mg of aspirin
.



AG
and congestive heart failure.
AG
remains one of the leading causes of development
heart failure. Control
high blood pressure, including measures to change
lifestyle and drug therapy,
improves heart function and prevents
the development of heart failure.
Patients with congestive heart
insufficiency have higher
the risk of death from cardiovascular
complications. So, the mortality rate for
year is approximately 10%.
Demonstrated a decrease in mortality
in this group the application of inhibitors
ACE and -blockers
(CIBIS II, MERIT-HF). The high efficiency
combination therapy with inhibitors
ACE and ,
-adrenoblokatorom
the carvedilol. Favorable effects
calcium antagonists in heart
failure is not proven. Installed
the safety of the use of amlodipine and
felodipine for the treatment of angina and
Hypertension in patients with severe left ventricular
dysfunction when used in
combination with ACE inhibitors, diuretics
or digoxin. The use of other
calcium antagonists in this group
patients is not recommended.



AG
and kidney disease.
When
proven capabilities significant
reduce the incidence of stroke and CHD in
the treatment of hypertension was designated a new problem
in the form of increasing frequency of renal
failure in patients with hypertension,
the number receiving treatment. AG can be
both a cause and consequence of nephropathy.
However, in any case, it is
the main risk factor for progression
the kidney damage. On the other hand, the levels
creatinine and proteinuria allow
to predict the development of not only
renal failure, but the main
cardiovascular complications. Risk
development of cardiovascular complications
in the presence of nephropathy is comparable to
those with cardiovascular
diseases. Diabetic nephropathy,
hypertensive nephropathy and primary
glomerulonephritis are the main
the causes of kidney failure.
It is proved that the normalization of HELL leads
to slow down the progression of the lesion
kidneys. Non-drug treatments
provide for reduction in consumption
sodium and protein intake. At a speed of
glomerular filtration rate less than 30 ml/min.
should monitor the consumption
potassium and phosphorus from food. ACE inhibitors
should be used with caution
when the level of creatinine more than 265 µmol/L.
Thiazide diuretics are ineffective when
renal failure
(creatinine 220 µmol/l)
justifies the use of a loop
diuretics, or their combination.
Potassium-sparing diuretics are contraindicated.



AG
and diabetes.
AG
more common in diabetes
Type II. Presumably AG and violations
carbohydrate metabolism of pathogenic
interrelated and are the consequence of
insulin resistance-hyperinsulinemia.
A combination of disorders of carbohydrate metabolism,
Hypertension, dyslipidemia and Central obesity
it is known as metabolic syndrome.
The combination of diabetes and hypertension increases
the risk of developing microvascular and
macrovascular disorders and, respectively
cardiac death, coronary artery disease, heart
failure, cerebral complications
and peripheral vascular disease.
Macrovascular complications are in
most deaths have
patients with diabetes, at that time
as in the absence of the AG noted an increase in
life expectancy of these patients.
Microvascular complications result
to the development of diabetic nephropathy and
retinopathy in turn increases
mortality. Progressive decline
renal function observed in patients
diabetes and hypertension, most pronounced in
the presence of microalbuminuria and proteinuria,
can be slowed by intensive
antihypertensive therapy. Effective
non-pharmacological treatment
is the normalization of body weight. It is important
strict adherence to the diet
as for the normalization of carbohydrate and
lipid metabolism and reduction
body mass and blood pressure. It is recommended to limit
salt consumption to 3 g/day. Special
attention should be paid to physical
exercise (brisk walking – 30 min
day, swimming up to 1 hour 3 times a week),
regular performance of which has
a beneficial effect on
sensitivity to insulin, the level
HELL and lipid metabolism (table. 14). However
note that excessive
physical activity can increase
the risk of hypoglycemia, especially when taking
alcohol. Preparations for the initial
therapy selected on the basis of common
principles of antihypertensive therapy
considering metabolic effects
antigipertenziveh funds. Thiazide
diuretics in high doses and -blockers
(especially nonselective) can cause
to the development of dyslipidemia and aggravation
insulin resistance. But when you apply
diuretics in patients with diabetes
diabetes decrease
cardiovascular mortality and
morbidity. b-Blockers can
potentially mask the symptoms
hypoglycemia. However, they proved
the effectiveness of secondary prevention
cardiovascular complications in
patients with myocardial infarction.
In patients with diabetes is recommended
avoid combination therapy
thiazide-and b-adrenoblokatorami.
It is appropriate combination
diuretics and ACE inhibitors. There
sufficient evidence of favorable
the effects of ACE inhibitors in patients
diabetes, kidney and heart
failure. Benefits blockers
angiotensin II receptor before
drugs of other classes is not proven.
They can recommended in case of intolerance
ACE inhibitors. It is assumed that
calcium antagonists have metabolic
neutrality. However, the appropriateness
use of calcium antagonists in
diabetes requires confirmation.
It is recommended to use products
prolonged action and to avoid
purpose digidropiridinove patients
where there is a history observed
ulcer trophic changes of the foot.
If microalbuminuria perhaps the appointment of
verapamil as monotherapy or
in combination with the ACE inhibitor.
-Blockers
are effective antihypertensive
means and have a positive
impact on metabolic parameters.
It is recommended to use long-term
existing drugs with the aim
warning orthostatic
hypotension.



AG
and dyslipidemia.
Significant
increase cardiovascular risk
the combination of dyslipidemia and hypertension
requires active treatment of both
States. To achieve the target
of lipid levels and blood pressure should
the use of the whole complex
non-drug and drug
events. The first step is a drug – free
methods of treatment, including normalization
of body weight, reducing consumption of animal
fat, salt, alcohol,
the increase in physical activity.
The thiazides and loop diuretics
in high doses it can lead to increased
levels of total cholesterol, triglycerides
and cholesterol LDL. These unwanted
effects of diuretics may be offset
through the appointment of thiazides in low
doses and dieting. -Blockers
can increase triglyceride levels
and reduce HDL cholesterol. The
in clinical studies
proven ability -blockers
to reduce overall mortality, risk of sudden
cardiac death and re-infarction
of the myocardium.

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