Blood vessel hypertension: new proposals

The new ESC/ESH guidelines recommend the use of short-term monitoring or judgment to analyze hypertension and prompt initiation of drug therapy using an appropriate renin-angiotensin mixture and calcium channel blockers or thiazide diuretics. The goal is to achieve a pulse of 120-129/70-79 mmHg in patients under 65 who can withstand it. For individuals north of 65, the target pulse should be 130-139/70-79 mmHg. Advances in rules, for example, the policy breakdown of evidence-based medication (EBM): specialists examine the information from the write-up and distributed consequences of clinical preparations to discover good practice suggestions. Since EBM does not have all the answers, the enforcement of rules that are not similarly accepted by all master assemblies can generate heated conversations. This happened in 2018 with the American (1) and European (2) guidelines for blood vessel hypertension.

Another meaning of hypertension is?

The SPRINT study, distributed in 2015 (3), considered two pulse target values ​​(<120 mmHg or <140 mmHg) exceeding 9,000 nondiabetic hypertensives (>130 mmHg) at high cardiovascular hazards. The review was hastily stopped and distributed after only 3 years, and the least objective population showed a 25% reduction in cardiovascular disease and all-cause mortality. The ACC-AHA rules distributed in 2018 (1) confirmed the consequences of the SPRINT study and suggested a different meaning of blood vascular hypertension (> 130/80 mmHg and not more than > 140/90 mmHg) with the prevalence of hypertension increases by half. . They also provide medical treatment up to 130/80 mmHg for potential countermeasures and high cardiovascular risk patients. Again, the ESC and ESH did not consider it worthwhile to change the meaning of blood vascular hypertension or to generally prescribe treatment up to 130/80 mmHg in their latest guidelines (2). Although they recognize the importance of the SPRINT trial, they note its limitations: most patients had blood pressure levels (>130 mmHg) recorded at enrollment and subsequently may not address true quality. Standard pulse values ​​were inconsistent, which is significant. HIGH: Therefore, this study cannot be used to suggest treatment above 130/80 mmHg or even more so to legitimize a different meaning of blood pressure. The strategy for pulse estimation (therefore without the presence of a specialist or nurse) lowers the target value: 120 mmHg refers to a higher value (130-139 mmHg) estimated using this technique: objective Use as little as conceivable to avoid fanaticism or even confusion, especially in elderly patients.

How to analyze hypertension?

The ESC/ESH guidelines emphasize, as, in the past, those reworked estimates are essential before diagnosing blood vessel hypertension, but they initially recommend ambulatory control (ABPM) or self-estimated circulatory strain (HBPM) as a symptomatic means. also, financial circumstances make this technique affordable.

The use of ABPM or LMWH allows a faster termination of vascular hypertension and, subsequently, a faster initiation of medical treatment in patients with high cardiovascular risk. In any case, the speed of handling the circulatory load is a decent prognostic element.

The guidelines suggest a correct range of 140/90 mmHg in a specialist's office:

The correlation of OBP information with ABPM or LMVH information characterizes 4 patient classifications:

- real standard time;

- true hypertension;

- white coat hypertensives (30-40% of hypertensives);

- patients with covered hypertension (with 15% normotensive control).

Contrary to what has been said for some time, white coat hypertension is definitely not a harmless condition. the visualization of these patients, if better than in true hypertensives, is moreover more deplorable than in true normotensives.

Covered hypertension is very difficult to visualize, indistinguishable, or worse than obvious hypertensives. Covered hypertension is more normal in young people, men, smokers, heavy drinkers, large, stationary, and individuals under pressure. It tends to be considered when there is an error between target organ damage and circulating voltage levels.

Cardiovascular Department of Gambling

It is important for the selection and visualization of restorative material and should be applied to all hypertensive patients.

Clinical history and circulatory stress levels now provide important data.

- patients with a cardiovascular history, confused diabetes, or GFR < 30 ml/min/1/73 m2 have an extremely high cardiovascular hazard;

- patients with simple diabetes, organ damage due to hypertension, or GFR < 60 ml/min/1.73 m2 are at high cardiovascular risk;

- Patients with blood vessel hypertension of the 3rd degree (> 180/110 mmHg) have the most unexpanded cardiovascular hazard.

Delineation of cardiovascular risk in patients with cardiovascular disease, diabetes, renal insufficiency, or organ damage due to hypertension can be done using the SCORE table (with a correction factor for original transitional states) (6). For young people, for whom the direct dangers revealed by the SCORE table are low most of the time, it could be very useful to use the idea of ​​cardiovascular age (the age that divides the hazard indistinguishable from the patient's hazard, without adjustment for risk factors). can be determined at www.heartscore.org.

When to start treatment?

A decrease of 10 mmHg in systolic heart rate or 5 mmHg in diastolic blood pressure reduces the risk of cardiovascular failure by 40%, the risk of stroke by 35%, and the risk of coronary heart disease or a major cardiovascular event by 20%. who, and everyone from the mortality rate - to 10-15%.

All patients should receive lifestyle and dietary management solutions. In addition, hypotensive treatment should first be approved for circulatory strain > 160/100 mmHg. (regardless of age) and in patients with high cardiovascular risk, pulse > 140/90 mmHg.

Low- or intermediate-risk patients younger than 80 years with a pulse > 140/90 mmHg should receive medical treatment if they remain hypertensive regardless of their 90-day lifestyle and diet. Treatment that has been proactively started cannot be interrupted after the age of 80 (basically not only with regard to advanced age).

Patients with a circulatory burden of 135-139/85-89 mm Hg should not receive clinical attention, except for those at high cardiovascular risk, in the event that lifestyle and diet do not suppress the pulse.

How to start treatment?

The rules further recognize 5 main classes of antihypertensive drugs: angiotensin-converting compound (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, beta-blockers, and diuretics.

However, they are imaginative in offering a decent mix (ACE inhibitor or ARB coupled with a calcium channel blocker or thiazide or comparable diuretic in a similar pill) as the best treatment option. The main exception is mild elderly patients and interesting high cardiovascular risk patients who should receive the recommended treatment for the high normal circulatory load.

The rationale for this decision depends on:

- the requirement for joint treatment of most patients;

- reduction of the heterogeneity of the reaction of the circulation strain in this type of mixture;

- the desire to quickly check the pulse, which works on visualization;

- improve consistency by improving handling.

Triple therapy including an ACE inhibitor or ARB, calcium-poor person, and thiazide diuretics is important when basic dual therapy is lacking.

The main special cases are sensitive elderly patients and rare patients with high cardiovascular risk for whom treatment is recommended.

The justification of the decision depends on the accompanying:

- Necessary for synchronous treatment of most patients;

- reducing the heterogeneity of the response to the pulse in this type of mixture;

- The desire to quickly check the pulse to work on expectations;

- Manipulation work and consistent work.

If basic dual therapy is insufficient, use triple therapy consolidating IECs or ARBs, calcium channel blockers, and thiazide diuretics.

Thiazide, chlorthalidone, and indapamide are excellent antihypertensive choices. There is a risk of insulin obstruction, which can be reduced with potassium or potassium-sparing diuretics. to be dosed.

Beta-blockers are not exceptionally persuasive in preventing stroke or in preventing left ventricular hypertrophy or turning it, and they are supported only for explicit symptoms (angina, rate control, post-mortem tissue, cardiovascular recompense). Shortage, young ladies who need to get pregnant) ).

What is your goal?

The main goal is for all patients to have a pulse < 140/90 mmHg, which currently occurs in less than 40% of treated patients [7].

More aggressive targets are suggested by the late meta-reviews and SPRINT studies and are also suggested by the ESC/ESH guidelines:

- A satisfactory objective value of the systolic pulse in patients younger than 65 years is 120-129 mmHg.

- Do not withhold any blood pressure of 130-139 mm Hg in patients aged 65 years and older and in patients with good renal impairment.

- Do not keep anything diastolic pressure 70-79 mm Hg.

These targets are lower than recently suggested, particularly in older patients, and miss the target levels established in the preliminary SPRINT evaluation for the reasons mentioned above. However, tool makers note the dangers that prevent less-tolerated treatment of incisors.

Unlike the KDIGO nephrology rule [8], which suggests a focus on circulatory strain <130/80 mmHg for proteinuria, the ESH rule does not suggest a focus on the low pulse in patients with proteinuric renal failure. The KDIGO rules for preventing the movement of kidney infections may make sense of this distinction.

fight hypertension

Safe hypertension is characterized as a pulse > 140/90 mmHg regardless of the use of at least 3 drugs, including diuretics.

You really want to see the conclusion:

- Fix estimation problems: incompressible odds or extremely tight sleeve;

- By checking drug consistency in light of clinical history, using exceptional surveys or estimates of blood or urine in hypotensive patients;

- Observation of gait or self-monitoring of circulatory strain.

In the event that there is no great explanation for elective hypertension, the guidelines suggest a bad person on mineralocorticoid receptors (spironolactone 25-50 mg/day) when GFR >45 mL/min/1.73 m2 and serum potassium <4.5 mEq /day. l. Eplerenone or amiloride may be an alternative if the antiandrogenic effects of spironolactone are not well tolerated.

Star Wars"

More recently, over-the-counter medications have been developed to treat hypertension.

- renal deliberate denervation;

- excitation of carotid baroreceptors;

- Production of femoral arteriovenous fistula.

These techniques are still being researched and their long viability and propriety are not set in stone. At this stage, they must be used in clinical trials to prove them, not as a feature of standard hypertension treatment.