home Thyroid Stage 1 hypertension complicated by diabetes mellitus. Arterial hypertension in diabetes mellitus: treatment of hypertension with medications and diet. What is diabetes

Stage 1 hypertension complicated by diabetes mellitus. Arterial hypertension in diabetes mellitus: treatment of hypertension with medications and diet. What is diabetes

Under the term " arterial hypertension", "arterial hypertension" refers to the syndrome of increased blood pressure (BP) in hypertension and symptomatic arterial hypertension.

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

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

Hypertension (HTN) is usually understood as a chronic disease, the main manifestation of which is arterial hypertension syndrome, not associated with the presence of pathological processes in which an increase in blood pressure (BP) is caused by known, in many cases remediable causes (“symptomatic arterial hypertension”) (WOK Recommendations, 2004).

Classification of arterial hypertension

I. Stages of hypertension:

Hypertension (HD) stage I assumes the absence of changes in “target organs”.
Hypertension (HD) stage II is established in the presence of changes on the part of one or more “target organs”.
Hypertension (HD) stage III established in the presence of associated clinical conditions.

II. Degrees of arterial hypertension:

The degrees of arterial hypertension (Blood Pressure (BP) levels) are presented in Table No. 1. If the values of systolic Blood Pressure (BP) and diastolic Blood Pressure (BP) fall into different categories, then a higher degree of arterial hypertension (AH) is established. The most accurate degree of Arterial Hypertension (AH) can be determined in the case of newly diagnosed Arterial Hypertension (AH) and in patients not taking antihypertensive drugs.

Table No. 1. Determination and classification of blood pressure (BP) levels (mm Hg)

The classification is presented before 2017 and after 2017 (in brackets)

Blood pressure (BP) categories	Systolic blood pressure (BP)	Diastolic blood pressure (BP)
Optimal blood pressure	< 120	< 80
Normal blood pressure	120-129 (< 120* )	80-84 (< 80* )
High normal blood pressure	130-139 (120-129* )	85-89 (< 80* )
1st degree hypertension (mild)	140-159 (130-139* )	90-99 (80-89* )
2nd degree hypertension (moderate)	160-179 (140-159* )	100-109 (90-99* )
AH of the 3rd degree of severity (severe)	>= 180 (>= 160* )	>= 110 (>= 100* )
Isolated systolic hypertension	>= 140

* - new classification of the degree of hypertension from 2017 (ACC/AHA Hypertension Guidelines).

III. Risk stratification criteria for patients with hypertension:

I. Risk factors:

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

b) Dyslipidemia
TC > 6.5 mmol/l (250 mg/dl)
LDL-C > 4.0 mmol/L (> 155 mg/dL)
HDL-C

c) (for women

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

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

e) :

- Sedentary lifestyle
- Increased fibrinogen

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

II. Target organ damage (stage 2 hypertension):

a) Left ventricular hypertrophy:
ECG: Sokolov-Lyon sign > 38 mm;
Cornell product > 2440 mm x ms;
EchoCG: LVMI > 125 g/m2 for men and > 110 g/m2 for women
Rg-graphy of the chest - cardio-thoracic index>50%

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

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

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

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

b) Dyslipidemia:
TC > 6.5 mmol/l (> 250 mg/dl)
or LDL-C > 4.0 mmol/L (> 155 mg/dL)
or HDL-C

V) Family history of early cardiovascular disease(among women

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

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

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

and) Left ventricular hypertrophy
ECG: Sokolov-Lyon sign > 38 mm;
Cornell product > 2440 mm x ms;
EchoCG: LVMI > 125 g/m2 for men and > 110 g/m2 for women
Rg-graphy of the chest - cardio-thoracic index>50%

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

And) Slight increase in serum creatinine 115-133 µmol/l (1.3-1.5 mg/dl) for men or 107-124 µmol/l (1.2-1.4 mg/dl) for women

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

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

m) Heart disease:
Myocardial infarction
Angina pectoris
Coronary revascularization
Congestive heart failure

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

O) Peripheral artery disease:
Dissecting aortic aneurysm
Symptomatic peripheral artery disease

P) Hypertensive retinopathy:
Hemorrhages or exudates
Papilledema

Table No. 3. Risk stratification of patients with arterial hypertension (AH)

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

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

Encephalopathy is a pathological (painful) change in the structures of the brain that disrupts its normal functioning. In diabetes, this condition occurs due to metabolic disorders, which, in turn, worsen the condition of blood vessels and nerve fibers. Diabetic encephalopathy can manifest itself in different ways, depending on the severity of the disease. In some patients, it makes itself felt only by headaches and memory impairment, in others it leads to serious mental disorders, seizures, etc. It is possible to prevent the severe consequences of encephalopathy by knowing about the causes and mechanisms of its occurrence and the principles of prevention.

Causes

Due to metabolic problems, toxic metabolites (end products of biochemical reactions) accumulate in the blood, which should normally be eliminated from the body. These toxins enter the brain and aggravate existing vascular disorders. First, individual cells of the nervous tissue are depleted, and over time, if blood circulation is not restored, they die completely. The more such areas in the brain, the worse the patient’s condition.

In addition to high blood sugar, there are additional factors that increase the risk of diabetic encephalopathy:

It is difficult to completely avoid problems with blood vessels in diabetes mellitus, because even with a mild course the disease leaves its mark on all organs and systems. But there is no need to specifically increase the risk of complications.

Symptoms

Manifestations of diabetic encephalopathy depend on its stage. At the initial stage, vascular disorders are manifested by increased fatigue, lack of strength, absent-mindedness, forgetfulness, dizziness and sleep disturbances. These symptoms are nonspecific, so it is difficult to make a diagnosis based on them alone. The same signs are found in many diseases of internal organs, disorders of the immune system, and simply due to overwork. But with encephalopathy, these symptoms persist for a long time and do not go away even after proper rest.

In the second stage of the disease, a person may experience frequent and severe headaches, nausea not associated with meals, dizziness and weakness. Memory lapses become more serious, and it becomes difficult for a diabetic to perceive large amounts of information. At this stage, a person begins to experience emotional disturbances. Unmotivated aggression and rudeness can give way to tearfulness or panic. The patient's intelligence is markedly reduced. He begins to think and reason more primitively.

As encephalopathy progresses, it enters the third stage, which is characterized by the following symptoms:

dementia;
problems with swallowing and chewing food;
unsteadiness of gait, inability to perform subtle movements that require precision;
speech defects;
severe mental disorders;
constant trembling of the hands;
surges in blood pressure.

The signs of the third stage are so pronounced that it is impossible not to notice them. Often the patient cannot adequately assess his condition; such a person loses the ability to think critically. Advanced encephalopathy leads to the disintegration of the patient’s personality. A person becomes suspicious, everything irritates or depresses him. Later, such diabetics experience fecal and urinary incontinence. In order to prevent serious consequences, when the first strange signs of the disease occur, you must consult a doctor for diagnosis and prescribing supportive treatment.

Treatment

Diabetic encephalopathy is a chronic condition that, unfortunately, cannot be completely eliminated. The prognosis depends on the stage at which the problem was discovered and on the overall severity of diabetes in the patient. The sooner treatment is started, the greater the chance of stopping the progression of the pathology and maintaining normal health for a long time.

To treat encephalopathy, diabetics can be prescribed drugs from the following groups:

medications to improve blood microcirculation;
B vitamins to support the nervous system;
medications to normalize blood pressure;
drugs that lower blood cholesterol levels (if necessary).

Another class that is often used to combat encephalopathy is nootropic drugs. They improve memory, normalize cognitive function of the brain and restore intelligence. Nootropic drugs also allow nerve fiber cells to more easily tolerate oxygen deprivation. The best effect from their use is noticeable at the beginning of therapy in the early stages of vascular disorders, although even in severe cases they can slightly improve the patient’s condition. Not all medications from this group are approved for the treatment of patients with diabetes, so their selection should only be done by a qualified doctor.

Since the true cause of encephalopathy in this case is diabetes mellitus, the patient needs to take medications that lower blood glucose levels. Depending on the type of disease, this can be either insulin or tablets. Non-drug methods of assistance that strengthen the functioning of the body are also important. First of all, it is diet and moderate exercise that help maintain target blood sugar levels.

Prevention

Since the symptoms of diabetic encephalopathy can cause significant discomfort to the patient, it is better to try to prevent their occurrence. The most effective way of prevention is to maintain blood sugar at a normal level and follow your doctor's recommendations regarding nutrition. Moderate physical activity (especially in the fresh air in the warm season) helps improve blood supply to all vital organs, including the brain. But if a diabetic suffers from high blood pressure, then before doing any physical exercise, he needs to consult a physician or cardiologist.

The patient's diet should be dominated by foods with a low and medium glycemic index, which improve the condition and functioning of the circulatory system.

These include:

citrus;
tomatoes;
garlic, onion;
pepper;
plums

Also useful for diabetics are foods that normalize blood pressure and contain a large amount of fiber (apples, nuts, kiwi, peas). You can reduce the likelihood of developing encephalopathy by including in your daily diet a small amount of olive oil, which contains vitamin E. All diabetics, and especially those who already have problems with blood pressure or blood vessels and heart, should give up alcohol and smoking.

Encephalopathy usually develops in old age, because, in addition to diabetes, natural degenerative processes begin to occur in the body. But in severe forms of diabetes, problems with cerebral vessels can occur even in very young people. No diabetic is immune from encephalopathy, so it is better not to neglect prevention. The disease, detected in the early stages, responds well to treatment, provided that all recommendations of the attending physician are followed. This will preserve a person’s ability to think normally and lead a normal lifestyle for a long time.

Controlling type 2 diabetes

The course of type 2 diabetes mellitus must be monitored almost more strictly than type 1 diabetes. In addition to blood sugar levels, monitoring such indicators as blood cholesterol, blood pressure, and body weight is also mandatory. These are all factors that contribute to the development of cardiovascular disease, and these factors are almost always present in a patient with type 2 diabetes.

To assess how well type 2 diabetes is compensated, you can focus on the indicators given in the table.

The worse the diabetes is compensated, the more severe its course and the higher the risk of complications, the earlier they will appear and the more severe they will be. And the more seriously you need to take treatment and lifestyle changes.

Diabetes compensation assessment

Blood and urine sugar levels

Blood and urine sugar levels are checked regularly using methods described for type 1 diabetes. True, with type 2 diabetes there is no need to do these tests before each meal: it is enough to determine the sugar level in the urine once a day, and in the blood - once every 3-5 days. During any illness (for example, the flu), as well as in case of deterioration in health, it is necessary to determine the sugar content in the blood and urine more often.

What test results can be considered satisfactory for a patient with type 2 diabetes? It depends on your age, and frankly speaking, on how many years you are going to live with “your” diabetes. With a blood sugar level not exceeding 8 mmol/l, serious vascular complications threaten you only after 30 years, with a sugar level above 10 mmol/l - already after 15-20 years.

Blood cholesterol levels

We have already said that metabolism is divided into separate “types” - carbohydrate, lipid (fat), protein - very arbitrarily. In diabetes mellitus, carbohydrate metabolism is impaired, but this cannot but affect other types of metabolism. In this case, we will talk about lipid metabolism disorders, which are the main risk factor for atherosclerosis, coronary heart disease and myocardial infarction - the main cause of mortality in the modern world.

Such an indicator of lipid metabolism as the content of total cholesterol in the blood is not particularly “indicative”. Patients with diabetes are recommended to regularly (at least once a year) have a lipid profile - an analysis of the ratio of different “types” (or, as they say in medicine, fractions) of lipids in the blood.

Lipids (fat-like substances) in the blood are represented by triglycerides and cholesterol, which are combined with proteins, so that it is not “fats” that circulate in the blood, but “fat-proteins” - lipoproteins. They all have different properties.

“Lipoproteins with cholesterol” are of two types. One type is very small particles called high-density lipoproteins, or HDL for short. The cholesterol they contain is called “good cholesterol”: it not only does not cause atherosclerosis, but, on the contrary, prevents its development.

The other type is larger, looser particles called low-density lipoprotein, or LDL. Normally, this is the main fraction of lipoproteins in the blood. However, the cholesterol they contain is called “bad” cholesterol because atherosclerosis develops when its level increases above 80%.

“Triglyceride lipoproteins” also come in two types: chylomicrons and very low-density lipoproteins (VLDL). Chylomicrons are normally detected in the blood only in infants after feeding; LDLNP is found in low concentrations in blood plasma taken on an empty stomach.
Normally, lipids in the blood are distributed according to the “1, 2, 3, 4, 5 rule” (in units of mmol/l; table):

Normal blood lipids

The risk of developing atherosclerosis increases with a reduced content of HDL in the blood, as well as with an increased content of LDL and VLDL. With diabetes, there is almost always a tendency to reduce the level of “good” cholesterol (HDL) and increase “bad” cholesterol, as well as triglycerides (LDL and VLDL).

In order to reduce this risk factor, people with lipid metabolism disorders are recommended, first of all, to adhere to an “anti-atherosclerotic” diet - containing no more than 100-300 mg of cholesterol per day. The fat content in the daily diet should not exceed 55-75 g, and the share of vegetable oils can be increased to 35-40%. The most useful are olive and flaxseed oils.

For a long time, nutritionists recommended that people with high levels of “bad” cholesterol in the blood sharply limit or completely eliminate the consumption of foods rich in animal fats: lard, fatty pork, beef and lamb, sausages, butter, heavy cream and sour cream, creams, as well as foods rich in cholesterol: egg yolks, kidneys, fish caviar, brain, liver. It has now been established that it is impossible to completely eliminate cholesterol from the diet; this is fraught with many unpleasant consequences for the body. Nevertheless, of course, it’s also not worth abusing foods rich in cholesterol, and not just those with diabetes.

If diet therapy for 2 months does not produce results (as can be judged by the lipid profile), lipid-lowering drugs are prescribed - statins (lovastatin, simvastatin, pravastatin, fluvastatin, atorvastatin, etc.) and fibrates (clofibrate, gemfibrozil, bezafibrate, ciprofibrate, fenofibrate) .

Arterial pressure

According to WHO definition, upper (systolic) pressure is considered elevated, starting from 140 mmHg. Art., lower (diastolic) - from 90 mm Hg. Art. There are three degrees of pressure increase:

up to 160/100 mm. rt. Art. - hypertension of the 1st degree (mild);
up to 180/110 mm. rt. Art. - hypertension 2nd degree (moderate)
over 180/110 mm. rt. Art. - hypertension of the 3rd degree (severe).

About 75% of patients with diabetes suffer from arterial hypertension, although it is impossible to say what is primary and what is secondary.

Persistently high blood pressure is called hypertension. It is divided into three stages, depending not even on the numbers, but on the degree of damage to the internal organs. In stage I there is no organ damage yet, and the pressure is moderately increased. At this stage there may be no complaints or they are quite vague - headaches, dizziness, sometimes tinnitus, spots before the eyes, palpitations. As a rule, at this stage, drugs to lower blood pressure are not yet prescribed - the patient is only advised to limit the consumption of table salt, lose weight and generally “normalize” their lifestyle. However, if hypertension is combined with diabetes mellitus, then already in stage I drug therapy is necessary, since in the presence of two such serious risk factors, the risk of myocardial infarction and stroke increases too much.

If the systolic blood pressure of a patient with diabetes mellitus exceeds 130 mmHg. Art., and diastolic - 85 mm Hg. Art., then he is prescribed medications to lower blood pressure, primarily belonging to the group of ACE inhibitors: berlipril, enalapril, captopril, capoten. At the same time, non-drug measures - combating excess weight, physical activity, limiting salt intake, stopping smoking - are still extremely important.

Hypertension stage 3, degree 3, risk 4: what is it?

To learn more…

Hypertension is a disease. Which in recent decades has become widespread among all segments of the population. The disease, the main symptom is a significant increase in blood pressure due to a number of reasons.

A report from the World Health Organization reports that hypertension occurs in every second inhabitant of the Earth.

Therefore, the problem of diagnosing and treating this disease has been brought to the forefront. This applies to everyone, and although absolute symptoms appear more often in older people, there is a disappointing progression - arterial hypertension is getting younger, affecting people under 30 years of age and even younger.

Often people do not pay attention to fleeting manifestations of high blood pressure until the disease progresses to the later stages, 3 and 4, respectively. It is these marginal states that are most dangerous. What is stage 3 hypertension and where does it come from?

Hypertension and hypertension

The scientific name of the disease is arterial hypertension, other analogues are only variations and outdated synonyms. It comes in two types.

Hypertension (the medical term is primary or essential arterial hypertension) is a persistent and prolonged increase in blood pressure of unknown origin.

This means that the cause of such a disorder is still not known to science, and everything is based only on assumptions.

It is believed that the human genome contains about twenty genes that in one way or another affect the functioning of the blood pressure control system. This disease accounts for more than 90% of all cases. Treatment consists of relieving dangerous symptoms and eliminating the consequences.

Secondary, or symptomatic arterial hypertension occurs due to diseases and dysfunction of the kidneys, endocrine glands, distorted innervation and malfunctions of the vasomotor center of the medulla oblongata, stress and caused by taking medications, also called iatrogenic.

Such hypertension must be treated etiologically, that is, eliminate the underlying cause, and not just lower the pressure.

Etiology and pathogenesis of disease development

In the age of genetic engineering, it is not difficult to determine that the dominant factor in the presence of high blood pressure is heredity. There is a high probability that if your parents complained of a stable increase in blood pressure, the disease will be passed on to you.

Next in importance, but not in frequency, is a feature of urban residents - a high frequency of stressful situations and a high pace of life. It has been scientifically proven that with significant psycho-emotional overloads, clusters of neurons drop out of common neural circuits, which leads to a disruption in their mutual regulation. The preponderance towards activating centers is inextricably linked with an increase in blood pressure.

Risk factors indicate those groups of people who have an increased likelihood of developing hypertension.

These include:

Older people. It is generally accepted that every person over 50 years of age suffers from arterial hypertension, even if they do not feel its primary symptoms. This is due to a decrease in the elasticity of blood vessels, as a result of their compensatory ability to withstand the force of heart contractions. Also, with age, the risk of atherosclerosis of large vessels increases, which leads to a narrowing of their lumen and the so-called jet movement of blood (like an airplane nozzle) through a small hole in the center of the shaft of fatty plaques.
Women. Research shows that girls and women are more likely to suffer from hypertension than men. The reason is a powerful hormonal background, which increases during pregnancy and disappears sharply upon the onset of menopause. Estrogens produced by the ovaries lower blood pressure, but they dominate only half of the menstrual cycle. When their production stops altogether, women begin to experience symptoms of high blood pressure.
Mineral imbalance. This category can be defined by a predilection for too salty foods, which increases the reabsorption of water in the nephron tubules and increases the volume of circulating blood, as well as reduced calcium intake. It, as the main cardiac ion, is necessary for the full functioning of the myocardium. Otherwise, arrhythmias and high arterial output are possible, which leads to increased blood pressure.
Alcohol and smoking. Bad habits themselves are incredibly harmful; they also damage the internal and elastic membranes of blood vessels, impairing their ability to adequately stretch and contract in time with the pulse wave. Constant sporadic contractions of blood vessels due to the action of nicotine and cigarette smoke leads to disruption of innervation and vascular pathology.

In addition, one of the factors is the presence of obesity and diabetes. Excess body weight is inextricably linked with physical inactivity. Such a hypertensive person leads an inactive lifestyle; due to the lack of regular exercise, his blood vessels lose their muscle element and do not respond to the regulation of the autonomic nervous system.

Additionally, the level of atherogenic lipids increases, which leak through the vascular endothelium, having a detrimental effect on them.

This dystrophy increases many times over with diabetes mellitus, because due to the dysfunction of the carbohydrate metabolic cauldron, fats are poorly oxidized and broken down, cannot be absorbed and circulate in the blood.

Degrees of arterial hypertension and possible outcomes

The clinic distinguishes four functional classes of hypertension, each of which has a special approach to diagnosis and treatment

In addition, there are several risk groups for developing complications of the disease.

Risk groups depend on the presence of certain factors complicating the course of the disease.

The following classification of arterial hypertension is possible according to the indicator of high blood pressure.

Degree 1 – systolic 140-159 / diastolic 90-99 mm Hg. Art.
Degree 2 – systolic 160-179 / diastolic 100-109 mmHg. Art.
Grade 3 – systolic 180+ / diastolic 110+ mmHg. Art.
Isolated systolic hypertension – systolic 140+ / diastolic 90.

From this classification it is obvious that the most dangerous is grade 3, which has the highest pressure, pre-hypertensive crisis. The degree is determined by ordinary pressure measurements using the Korotkoff method, but does not have clinical indications. To reflect changes in the organs most sensitive to increased blood pressure (the so-called target organs) and possible consequences, a classification by stage was developed. These organs include the brain, liver, kidneys, and lungs. The main signs are hemorrhages into the parenchyma of the organ with subsequent disruption of its function and the development of failure.

Stage 1 – no changes are detected in target organs. The outcome of such hypertension is the patient’s recovery with the right approach to treatment.

Stage 2 – if at least one organ is affected, then the patient is at this stage of the disease. At this stage, it is necessary to examine the affected area and contact a specialist. ECG, echocardiography, examination by an ophthalmologist for the presence of retinopathy during fundus examination (the most informative and easily diagnosed symptom at the moment), general and biochemical blood tests, urinalysis.

Stage 3 – a condition bordering on the occurrence of a hypertensive crisis. Characterized by the presence of multiple and extensive lesions in more than one target organ. These may be: hemorrhagic and ischemic strokes due to angiopathy of the brain vessels, encephalopathy of various origins, ischemic heart disease (coronary heart disease) with manifestations of angina pectoris (retrosternal pain that radiates to the left arm, neck, jaw), myocardial infarction with subsequent necrotic and toxic changes – Dressler's syndrome, reperfusion syndrome and cardiogenic shock. This will be followed by damage to the renal barrier, resulting in proteinuria, the processes of filtration and reabsorption of blood plasma in the nephron, and acute renal failure. Large vessels will be affected next, which will manifest as aortic aneurysm, massive atherosclerosis and damage to the coronary arteries. The retina is very sensitive to high blood pressure, which results in damage to the optic nerve and intraocular hemorrhages. This stage requires decisive measures to compensate for destructive processes with drugs.

Stage 4 is a terminal condition that, if persistent for more than a week, leads to irreversible disability.

In addition, there are several risk groups for developing complications:

first - at the time of examination there are no complications, and the probability of their development over 10 years is up to 15%;
second – three factors are present, and the risk of complications is no more than 20%;
third – the presence of more than three factors has been identified, the risk of complications is about 30%;
fourth - severe damage to organs and systems is detected, the risk of developing a heart attack and stroke is more than 30%.

Based on the above, it becomes clear what stage 3 hypertension is, risk 4. In simple words, the disease is deadly.

Treatment of hypertension

Arterial hypertension grade 3, risk 4, requires emergency care and cannot be delayed. The complications are the most unpleasant - heart attack, stroke, kidney failure.

In order not to wait for a hypertensive crisis, you need to call an ambulance as soon as possible if you have the main alarming symptoms - systolic pressure above 170, headaches of a dull diffuse nature, nausea of central origin due to high intracranial pressure (after vomiting with such nausea the condition does not improve), tinnitus due to increased blood flow, burning pain behind the sternum, weakness in the limbs and numbness.

There may be a sensation of “pins and needles” under the skin, progressive memory deterioration and a decrease in intellectual abilities, and deterioration of vision.

In this condition, physical activity and sudden movements are contraindicated; patients are strictly prohibited from undergoing surgery, giving birth, or driving a car.

Preparations of the main group, which are primarily used for hypertension:

Loop diuretics are substances that block the Na+K+Cl cotransporter in the ascending limb of the nephron's loop of Henle, which reduces fluid reabsorption and water does not return to the bloodstream, but is intensively excreted from the body. The volume of circulating blood decreases, and with it blood pressure. These drugs include Furosemide (aka Lasix), Indapamide (also known as Indap or Arifon), Hydrochlorothiazide. They are used most often because they are inexpensive compared to analogues.
Beta blockers. They reduce the contractility of the heart, which increases with stage 3 hypertension, by blocking the adrenergic synapses of the myocardium. Medicines in this group include Anaprilin (Propranolol), Atenolol (Atebene), Cordanum, Metoprolol (there are forms Specicor, Corvitol and Betaloc), Nebivalol. These medications must be used strictly according to the instructions, because an extra blocker tablet can lead to conduction and automaticity disorders and arrhythmias.
Angiotensin-converting enzyme inhibitors. Angiotensin greatly increases blood pressure, and if its production is interrupted at the level of tissue angiotensinogen, then you can quickly and effectively relieve the symptoms of stage 3 hypertension even with a risk of 4. The most famous representatives of the group are Captopril (Capoten), Captopress, Enap (Renitek), Lisinopril. It is possible to directly block angiotensin receptors with Losartan.
Calcium antagonists - Nifedipine and Amlodipine - reduce the force of cardiac contraction and the volume of stroke blood ejection, thereby lowering blood pressure.

Hypertension and hypertensive crisis can be prevented at home. The basis of the method is a strict diet as the main way of therapeutic influence, in particular the use of lightly salted table No. 10 according to Pevzner.

It includes wheat bread, lean meats, fiber-rich salads, boiled eggs, fermented milk drinks, and soups. It is imperative to limit salt intake to 6 g per day. Folk remedies include sedatives - valerian, motherwort, peppermint, hawthorn.

Stage 3 hypertension is discussed in the video in this article.

Stabilizes sugar levels for a long time
Restores insulin production by the pancreas

To learn more…

Moscow State Medical and Dental University named after. Evdokimova

Department of Evidence-Based Medicine

Head of the department: Doctor of Medical Sciences, Professor R.I. Stryuk

Teacher: Ph.D. , Associate Professor, Buldakova Yu.R.

Medical history analysis

Completed by a student

course 604 gr.

Faculty of Medicine, Evening Department

Maltseva E.S.

cardiosclerosis cardiac vascular therapy

Moscow 2013

The front side of the title page of the medical history is neatly designed

The corresponding columns indicate the date and time of admission to the emergency department (7.32 March 25, 2013); method (gravity) and type of transportation (on a chair) to the second therapeutic department.

The passport part is completely filled out

The clinical diagnosis is indicated: Hypertensive crisis. IHD. Atherosclerotic cardiosclerosis. NK II A. BPVLNPG. Hypertension III. Diabetes mellitus type 2.

The diagnosis only indicates the stage of hypertension, does not indicate the degree of hypertension and the risk of cardiovascular complications, and does not indicate the severity and compensation of diabetes mellitus.

Diagnosis: Hypertensive crisis. IHD. Atherosclerotic cardiosclerosis. NK II A. BPVLNPG. Hypertension stage III, degree 3. Risk 4. Diabetes mellitus type 2, moderate severity, subcompensation.

the degree was set on the basis of blood pressure numbers: 200/120 mmHg. (more than 180/110 mmHg)

The patient was assigned risk 4 (very high) based on the presence of type II diabetes mellitus.

(#"justify"> - Weight, height, body temperature, blood type, Rh factor, presence or absence of drug intolerance are not indicated, diagnosis on admission is not indicated.

History of the disease - worsening of the condition this morning. Brought to the hospital by her daughter, who works as a nurse in the 2nd hospital. HD II, IHD, AMI? Diabetes mellitus type 2. Sugar in the morning 6.6 mmol/l.

Those reflected in the medical history are uninformative, the anamnesis is not fully collected. It is not indicated when the first complaints appeared; how long the patient has been suffering from hypertension and diabetes mellitus; the nature and location of the headache and the time of their occurrence are not indicated. Did the patient go to the clinic, was she examined, was she prescribed medications. There is no information about whether or not she took medications; if she did, then which ones, in what dose, with what effect.

The patient spent 58 minutes in the emergency department, during which time the following studies were performed:

ECG Conclusion: Sinus rhythm. Severe LV hypertrophy. Scar changes in the LV myocardium.

CBC: leukocytes 4.9; Hb 151.7; red blood cells 5.02; neutrophils 30.1%; lymphocytes 53.6%; monocytes 12%; ESR 16

TAM: leukocytes 25, specific gravity 1005.

X-ray examination: not performed due to delays in the X-ray room.

In the emergency department, the patient’s blood glucose was not tested, which was indicated in the presence of a history of diabetes mellitus (National Clinical Guidelines for Cardiology 2009 Mandatory Tests).

The medical history contains the patient’s signed Agreement with the general examination and treatment plan, consent to the processing of personal data, and guarantees of confidentiality.

4. Assistance provided in the emergency department: Capoten 25 mg was provided correctly. (#"justify">8. Treatment

general regimen, diet No. 9,

Since the patient suffers from diabetes mellitus, she is indicated for combination antihypertensive therapy: When choosing a drug, preference is given to ACE inhibitors, especially in the presence of proteinuria, calcium antagonists and low doses of diuretics (N/a: enalapril + indapamide). #"justify">The patient is being treated at the 2nd tertiary center from 03.25.13 to 03.9.13 (day of supervision), there is no staged epicrisis in the medical history.

9. Basic recommendations for the patient after discharge:
Non-drug methods include:
normalization of body weight (BMI< 25 кг/м2.);
increasing physical activity - regular physical activity for 30-40 minutes at least 4 times a week;
reducing table salt consumption to 5 g/day;
changing the diet with an increase in the consumption of plant foods, an increase in the diet of potassium, calcium (found in vegetables, fruits, grains) and magnesium (found in dairy products), as well as a decrease in the consumption of animal fats.
Following a diet that excludes the consumption of easily digestible carbohydrates
Combination drug therapy:
AT1 receptor blockers (Bloktran)
β- adrenergic blockers (Carvedilol)
Antiplatelet agent (Cardiomagnyl)
Statins (Atomax)
Hypoglycemic drug from the sulfonylurea group of the second generation (Diabeton)

observation by a local therapist, cardiologist and endocrinologist.

The combination of diseases such as arterial hypertension and diabetes mellitus requires special attention from the patient and the doctor. Hypertension does not increase the likelihood of diabetes, but diabetes is a known risk factor for hypertension. It is accompanied by increased blood pressure in at least a third of patients. Hypertension significantly increases the risk of damage to the coronary and renal arteries in patients with diabetes, which worsens the prognosis of the disease. Therefore, timely detection and treatment of high blood pressure is important.

Read in this article

Forms of the disease

Elevated glucose levels in diabetes damage the inner surface of the vascular bed. This disrupts the production of vasodilator substances in it, reduces the elasticity of the arteries and leads to the development of hypertension.

When the kidney vessels are damaged, which is typical for diabetes, diabetic nephropathy occurs. At the same time, the kidneys begin to secrete many vasoconstrictor substances that cause.

Key treatment goals

Hypertension and diabetes mellitus aggravate each other. The progression of the pathology is accompanied by an increased risk of complications (heart attack, stroke, heart failure) and renal failure.

Treatment of arterial hypertension in diabetes mellitus has the following main goals:

reducing the risk of complications from the heart and blood vessels;
reducing mortality from these complications;
prevention of renal failure;
improving the patient's quality of life;
maintaining normal blood glucose levels (neutral effect on carbohydrate metabolism).

Therapy begins in a situation where a person with diabetes has a pressure level greater than or equal to 130/85 after several measurements. It is necessary to select a combination of medications to maintain blood pressure no more than 130/80. In the case of severe kidney damage, accompanied by a daily protein excretion of more than 1.0 g, a blood pressure value of no higher than 125/75 mmHg should be achieved. Art.

Choice of drugs

Treatment of hypertension in diabetes mellitus should begin with angiotensin-converting enzyme inhibitors (ACEIs). Their effectiveness has been proven by international studies.

If ACE inhibitors are insufficiently effective, calcium antagonists (amlodipine, felodipine) are added to therapy. This combination protects the heart from the harmful effects of excess glucose.

If necessary, ACE inhibitors can be combined with diuretics. Preference should be given to indapamide, as the most neutral drug of all diuretics.

If arterial hypertension in patients with diabetes mellitus is combined with coronary heart disease (angina pectoris, previous heart attack), beta blockers should be added to treatment. You need to choose those that do not affect carbohydrate metabolism. These medications include cardioselective beta blockers, in particular bisoprolol, carvedilol, nebivolol. These medications should be used to prevent heart attack and sudden death.

The choice of medication also depends on its effect on kidney function. It has been proven that ACE inhibitors and indapamide reduce protein excretion in the urine and thereby prevent the development of renal failure; calcium antagonists (and diltiazem) have the same effect. These drugs can also be used in the complex treatment of hypertension in diabetes. In case of intolerance to ACE inhibitors, angiotensin II receptor blockers (valsartan) are prescribed.

The effect of medications on the general condition

Some medications for hypertension have a negative effect on carbohydrate metabolism, so their use is not recommended for diabetes. This also applies to beta-blockers.

The most commonly used thiazide diuretic is hypothiazide. It may cause an increase in fasting blood glucose levels and glycosylated hemoglobin concentrations. While taking it, tolerance () to glucose worsens. There are cases where non-ketonemic hyperosmolar coma developed while taking hypothiazide. This is due to the suppression of insulin secretion and a decrease in tissue sensitivity to this hormone.

Beta-blockers also have an adverse effect on the course of diabetes. These drugs:

inhibit insulin production;
increase tissue resistance to it (insulin resistance);
suppress the absorption of sugar by cells;
increase the secretion of growth hormone - an insulin antagonist.

As a result, fasting and postprandial glucose levels increase. Cases of diabetic coma have been reported.

Beta blockers mask the symptoms of low blood glucose, making it difficult to diagnose hypoglycemia. They also inhibit the emergency release of carbohydrates from the liver, for example, during physical activity. This leads to more frequent development of hypoglycemic conditions.

Medicines from this group such as propranolol (obzidan), nadolol and timolol are contraindicated for people with diabetes. The use of high doses (more than 25 mg) of atenolol and metoprolol is extremely undesirable.

Studies have shown that even in individuals with normal blood glucose levels, long-term treatment with thiazides and beta blockers has a higher risk of developing diabetes than with treatment with ACE inhibitors.

Prevention of hypertension in diabetes

To avoid severe complications of these diseases, the patient should reduce salt intake and increase physical activity. Walking for 20 to 30 minutes per day or any vigorous outdoor activity for 90 minutes per week is recommended. It is advisable to avoid using the elevator and using a car where you can walk.

It is important to follow a low-calorie diet, limiting the intake of salt, sugar, meat and fatty dairy products. These measures are aimed at treating obesity. Excess weight is an important factor in the onset and progression of diabetes. Normalizing body weight improves tissue absorption of glucose and causes a significant decrease in blood pressure.

eat more vegetables and fruits;
consume only low-fat dairy products;
avoid salty and fried foods, use steaming or baking more often;
eat whole grain bread, brown rice, pasta made only from durum wheat;
reduce the amount of food you eat;
be sure to have breakfast.

Often, people with diabetes experience “masked” hypertension, which is not detected with rare measurements, but has a bad effect on the condition of blood vessels. Therefore, all patients with diabetes need to regularly monitor 24-hour blood pressure. Drug treatment should be started when the normal levels are slightly exceeded.

People with diabetes should measure blood pressure not only while sitting, but also while standing. This helps to recognize orthostatic hypotension in time, requiring a reduction in the dose of antihypertensive drugs. It is necessary to monitor the level of cholesterol in the blood and prescribe medications to reduce it in time.

Diabetes mellitus is often complicated by hypertension or secondary arterial hypertension. The combination of these two diseases increases the risk of complications from the heart, kidneys, eyes, brain and other organs. To avoid this, you need to monitor your activity regimen, diet, get examined on time and take medications prescribed by your doctor.

Arterial hypertension and diabetes mellitus

Diabetes mellitus and arterial hypertension are two interrelated pathologies that have a powerful mutually reinforcing damaging effect aimed at several target organs at once: the heart, kidneys, brain vessels, retinal vessels. The main causes of high disability and mortality in patients with diabetes mellitus with concomitant arterial hypertension are: coronary heart disease, acute myocardial infarction, cerebrovascular accidents, and end-stage renal failure. It has been established that an increase in diastolic blood pressure (BP) for every 6 mm Hg. increases the risk of developing coronary artery disease by 25%, and the risk of developing stroke by 40%. The rate of onset of end-stage renal failure with uncontrolled blood pressure increases 3-4 times. Therefore, it is extremely important to recognize and diagnose both diabetes mellitus and associated arterial hypertension early in order to prescribe appropriate treatment in time and stop the development of severe vascular complications.

Arterial hypertension complicates the course of both DM 1 and DM 2. In patients with DM 1, the main cause of the development of hypertension is diabetic nephropathy. Its share is approximately 80% among all other causes of increased blood pressure. With diabetes mellitus 2, on the contrary, in 70-80% of cases essential hypertension is detected, which precedes the development of diabetes mellitus itself, and only in 30% of patients arterial hypertension develops as a result of kidney damage.

Treatment of arterial hypertension (AH) is aimed not only at lowering blood pressure (BP), but also at correcting risk factors such as smoking, hypercholesterolemia, and diabetes mellitus

Combination diabetes mellitus and untreated arterial hypertension is the most unfavorable factor in the development of coronary heart disease, stroke, heart and kidney failure. Approximately half of patients with diabetes have arterial hypertension.

What is diabetes?

Sugar is the main source of energy, “fuel” for the body. Sugar is found in the blood in the form of glucose. The blood carries glucose to all parts of the body, especially to the muscles and brain, which glucose supplies with energy.

Insulin is a substance that helps glucose enter the cell to carry out life processes. Diabetes is called “sugar disease” because in this disease the body is unable to maintain normal blood glucose levels. Type II diabetes mellitus is caused by insufficient insulin production or low cell sensitivity to insulin.

What are the initial manifestations of diabetes mellitus?

The initial manifestations of the disease are thirst, dry mouth, frequent urination, itchy skin, and weakness. In this situation, you need to test your blood sugar levels.

What are the risk factors for developing type 2 diabetes?

Heredity. Those people who have a family history of diabetes are more susceptible to developing diabetes.

Overeating and excess body weight. Overeating, especially excess carbohydrates in food, and obesity are not only a risk factor for diabetes, but also worsen the course of this disease.

Arterial hypertension. The combination of hypertension and diabetes mellitus increases the risk of developing coronary heart disease, stroke, and renal failure by 2-3 times. Research has shown that treating hypertension can significantly reduce this risk.

Age. Type diabetes is also often called diabetes of the elderly. At the age of 60, every 12th person has diabetes.

Do people with diabetes have an increased risk of developing arterial hypertension?

Diabetes mellitus leads to vascular damage (large and small arteries), which further contributes to the development or worsening of arterial hypertension. Diabetes contributes to the development of atherosclerosis. One of the reasons for increased blood pressure in patients with diabetes is kidney pathology.

However, half of the patients suffering from diabetes mellitus already had arterial hypertension at the time of detection of elevated blood sugar. You can prevent the development of hypertension in diabetes if you follow recommendations for maintaining a healthy lifestyle. If you have diabetes, it is very important to regularly measure your blood pressure and follow your doctor's diet and treatment instructions.

What is the target blood pressure level for diabetes?

Target blood pressure is the optimal blood pressure level, the achievement of which can significantly reduce the risk of developing cardiovascular complications. When diabetes mellitus and hypertension are combined, the target blood pressure level is less than 130/85 mmHg.

What are the criteria for the risk of developing renal pathology with a combination of diabetes mellitus and hypertension?

If your urine tests reveal even a small amount of protein, you have a high risk of developing kidney disease. There are many methods for testing kidney function. The simplest and most common is determining the blood creatinine level. Important tests for regular monitoring are the determination of glucose and protein in the blood and urine. If these tests are normal, there is a special test to detect small amounts of protein in the urine - microalbuminuria - an initial disorder of kidney function.

What are the non-drug treatments for diabetes?

Changing your lifestyle will help you not only control your blood pressure, but also maintain normal blood sugar levels. These changes include: strict adherence to dietary recommendations, loss of excess body weight, regular exercise, reducing the amount of alcohol consumed, and stopping smoking.

What antihypertensive drugs are preferred for the combination of hypertension and diabetes mellitus?

Some antihypertensive drugs can negatively affect carbohydrate metabolism, so the selection of medications is carried out individually by your doctor. Preference in this situation is given to a group of selective imidazoline receptor agonists (for example, Physiotens) and AT receptor antagonists that block the action of angiotensin (a powerful vascular constrictor).

For prevention and treatment hypertension And type 2 diabetes mellitus

Reasons for the development of arterial hypertension in diabetes

Diabetes mellitus (DM), as defined by I. I. Dedov, is a systemic heterogeneous disease caused by absolute (type 1) or relative (type 2) insulin deficiency, which first causes disturbances in carbohydrate metabolism, and then in all types of metabolism substances, which ultimately leads to damage to all functional systems of the body (1998).

In recent years, diabetes has been recognized as a worldwide non-infectious pathology. Every decade, the number of people developing diabetes almost doubles. According to the World Health Organization (WHO), in 1994 the number of people with diabetes worldwide was about 110 million, in 2000 about 170 million, in 2008 - 220 million, and it is expected that by 2035 this number will exceed 300 million people. In the Russian Federation, according to the State Register, in 2008, about 3 million patients with type 2 diabetes were registered.

During the course of the disease, both acute and late vascular complications can occur. The incidence of acute complications, which include hypoglycemic and hyperglycemic comatose states, has decreased significantly in recent years due to improvements in diabetes therapy. The mortality rate of patients from such complications does not exceed 3%. The increase in life expectancy of patients with diabetes has brought to the fore the problem of late vascular complications, which pose a threat of early disability, worsen the quality of life of patients and shorten its duration. Vascular complications determine the statistics of morbidity and mortality in diabetes. Pathological changes in the vascular wall disrupt the conduction and damping functions of blood vessels.

Diabetes and arterial hypertension (AH) are two interrelated pathologies that have a powerful mutually reinforcing damaging effect aimed at several target organs: the heart, kidneys, blood vessels of the brain and retina.

Approximately 90% of the population of diabetic patients have type 2 diabetes (non-insulin-dependent), more than 80% of patients with type 2 diabetes suffer from hypertension. The combination of diabetes and hypertension leads to early disability and death of patients. Hypertension complicates the course of both type 1 diabetes and type 2 diabetes. Correction of blood pressure (BP) is a primary goal in the treatment of diabetes.

Reasons for the development of arterial hypertension in diabetes

The mechanisms of development of hypertension in type 1 and type 2 diabetes differ.

In type 1 diabetes, hypertension is a consequence of diabetic nephropathy - 90% of all other causes of high blood pressure. Diabetic nephropathy (DN) is a collective concept that unites various morphological variants of kidney damage in diabetes, including arteriosclerosis of the renal artery, urinary tract infection, pyelonephritis, papillary necrosis, atherosclerotic nephroangiosclerosis, etc. There is no single classification. Microalbuminuria (early stage of DN) is detected in patients with type 1 diabetes with a disease duration of less than 5 years (according to EURODIAB studies), and an increase in blood pressure is usually observed 10–15 years after the onset of diabetes.

The process of development of DN can be represented as an interaction between the triggering cause, progression factors and “mediators” of progression.

The triggering factor is hyperglycemia. This condition has a damaging effect on the microvasculature, including the glomerular vessels. Under conditions of hyperglycemia, a number of biochemical processes are activated: non-enzymatic glycosylation of proteins, as a result of which the configuration of the proteins of the basement membrane of the capillaries (BMC) of the glomerulus and mesangium is disrupted, and a loss of charge and size selectivity of the BMC occurs; the polyol pathway of glucose metabolism is disrupted - the conversion of glucose into sorbitol with the participation of the enzyme aldose reductase. This process predominantly occurs in those tissues that do not require the presence of insulin for the penetration of glucose into cells (nerve fibers, lens, vascular endothelium and glomerular cells). As a result, sorbitol accumulates in these tissues and intracellular myoinositol reserves are depleted, which leads to disruption of intracellular osmoregulation, tissue edema and the development of microvascular complications. These processes also include direct glucotoxicity associated with activation of the enzyme protein kinase C, which leads to increased permeability of vessel walls, acceleration of tissue sclerosis, and disruption of intraorgan hemodynamics.

Hyperlipidemia is another triggering factor: for both type 1 diabetes and type 2 diabetes, the most characteristic disorders of lipid metabolism are the accumulation in the blood serum of atherogenic low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL) cholesterol and triglycerides. Dyslipidemia has been proven to have nephrotoxic effects. Hyperlipidemia causes damage to the capillary endothelium, damage to the glomerular basement membrane, proliferation of the mesangium, which entails glomerulosclerosis and, as a result, proteinuria.

The result of exposure to these factors is the progression of endothelial dysfunction. This disrupts the bioavailability of nitric oxide due to a decrease in its formation and increase in destruction, a decrease in the density of muscarinic-like receptors, the activation of which leads to the synthesis of NO, an increase in the activity of the angiotensin-converting enzyme on the surface of endothelial cells, which catalyzes the conversion of angiotensin I to angiotensin II, as well as the production endothelin I and other vasoconstrictor substances. An increase in the formation of angiotensin II leads to spasm of the efferent arterioles and an increase in the ratio of the diameter of the afferent and efferent arterioles to 3–4:1 (normally this figure is 2:1), and, as a result, intraglomerular hypertension develops. The effects of angiotensin II also include stimulation of constriction of mesangial cells, as a result of which the glomerular filtration rate decreases, the permeability of the glomerular basement membrane increases, and this, in turn, contributes to the occurrence of first microalbuminuria (MAU) in patients with diabetes, and then severe proteinuria. The protein is deposited in the mesangium and interstitial tissue of the kidneys, growth factors, proliferation and hypertrophy of the mesangium are activated, overproduction of the basic substance of the basement membrane occurs, which leads to sclerosis and fibrosis of the renal tissue.

The substance that plays a key role in the progression of both renal failure and hypertension in type 1 diabetes is angiotensin II. It has been established that the local renal concentration of angiotensin II is thousands of times higher than its content in plasma. The mechanisms of the pathogenic action of angiotensin II are due not only to its powerful vasoconstrictor effect, but also to proliferative, prooxidant and prothrombogenic activity. High activity of renal angiotensin II causes the development of intraglomerular hypertension and promotes sclerosis and fibrosis of renal tissue. At the same time, angiotensin II has a damaging effect on other tissues in which its activity is high (heart, vascular endothelium), maintaining high blood pressure, causing remodeling of the heart muscle and the progression of atherosclerosis. The development of arteriosclerosis and atherosclerosis is also promoted by inflammation, increased calcium-phosphorus product and oxidative stress.

In type 2 diabetes, the development of hypertension in 50–70% of cases precedes a disturbance in carbohydrate metabolism. These patients have been observed for a long time with a diagnosis of “essential hypertension” or “hypertension.” As a rule, they have excess body weight, lipid metabolism disorders, and later they develop signs of impaired carbohydrate tolerance (hyperglycemia in response to a glucose load), which then transforms into a full-blown picture of type 2 diabetes in 40% of patients. In 1988, G. Reaven suggested that the development of all these disorders (hypertension, dyslipidemia, obesity, impaired carbohydrate tolerance) is based on a single pathogenetic mechanism - the insensitivity of peripheral tissues (muscle, adipose, endothelial cells) to the action of insulin (the so-called insulin resistance). This symptom complex is called “insulin resistance syndrome,” “metabolic syndrome,” or “syndrome X.” Insulin resistance leads to the development of compensatory hyperinsulinemia, which can maintain normal carbohydrate metabolism for a long time. Hyperinsulinemia, in turn, triggers a cascade of pathological mechanisms leading to the development of hypertension, dyslipidemia and obesity. The relationship between hyperinsulinemia and hypertension is so strong that if a patient has a high concentration of plasma insulin, it is possible to predict that he will soon develop hypertension.

Hyperinsulinemia increases blood pressure levels through several mechanisms:

— insulin increases the activity of the sympathoadrenal system;

- insulin increases the reabsorption of sodium and fluid in the proximal tubules of the kidneys;

— insulin, as a mitogenic factor, increases the proliferation of vascular smooth muscle cells, which narrows their lumen;

— insulin blocks the activity of Na-K-ATPase and Ca-Mg-ATPase, thereby increasing the intracellular content of Na+ and Ca++ and increasing the sensitivity of blood vessels to the effects of vasoconstrictors.

Thus, hypertension in type 2 diabetes is part of a general symptom complex based on insulin resistance.

What causes the development of insulin resistance itself remains unclear. Research results from the late 90s suggest that the development of peripheral insulin resistance is based on hyperactivity of the renin-angiotensin system. Angiotensin II in high concentrations competes with insulin at the level of insulin receptor substrates (IRS 1 and 2), thereby blocking post-receptor insulin signaling at the cellular level. On the other hand, existing insulin resistance and hyperinsulinemia activate AT1 receptors of angiotensin II, leading to the implementation of mechanisms for the development of hypertension, chronic kidney disease and atherosclerosis.

Thus, in both type 1 diabetes and type 2 diabetes, the main role in the development of hypertension, cardiovascular complications, renal failure and the progression of atherosclerosis is played by the high activity of the renin-angiotensin system and its final product, angiotensin II.

For prevention and treatment hypertension And type 2 diabetes mellitus at home, use the MED-MAG pulsating laser of the wrist and nose type.

Clinical features of hypertension in diabetes

No nighttime decrease in blood pressure

Daily blood pressure monitoring in healthy people reveals fluctuations in blood pressure values at different times of the day. The maximum level of blood pressure is observed during the daytime, and the minimum during sleep. The difference between daytime and nighttime blood pressure readings should be at least 10%. Daily fluctuations in blood pressure depend on the activity of the sympathetic and parasympathetic nervous system. However, in some cases, the normal daily rhythm of blood pressure fluctuations may be disrupted, which leads to unreasonably high blood pressure values at night. If patients with hypertension maintain a normal rhythm of fluctuations in blood pressure levels, then such patients are classified as “dippers”. Those patients who do not have a decrease in blood pressure during night sleep are classified as “non-dippers.”

A study of diabetic patients with hypertension showed that most of them belong to the category of “non-dippers,” i.e., they do not have a normal physiological decrease in blood pressure at night. Apparently, these disorders are caused by damage to the autonomic nervous system (autonomic polyneuropathy), which has lost the ability to regulate vascular tone.

Such a perverted daily rhythm of blood pressure is associated with the maximum risk of developing cardiovascular complications for both patients with diabetes and without diabetes.

Positional hypertension with orthostatic hypotension

This is a common complication observed in patients with diabetes, which significantly complicates the diagnosis and treatment of hypertension. In this condition, a high level of blood pressure is determined in the supine position and its sharp decrease when the patient moves to a sitting or standing position.

Orthostatic changes in blood pressure (as well as distortion of the circadian rhythm of blood pressure) are associated with a complication characteristic of diabetes - autonomic polyneuropathy, as a result of which the innervation of blood vessels and the maintenance of their tone are disrupted. The presence of orthostatic hypotension can be suspected based on the patient’s typical complaints of dizziness and darkening of the eyes when abruptly rising from bed. In order not to miss the development of this complication and to choose the right antihypertensive therapy, the blood pressure level in patients with diabetes should always be measured in two positions - lying and sitting.

Hypertension on a white coat

In some cases, patients experience an increase in blood pressure only in the presence of a doctor or medical personnel performing the measurement. At the same time, in a calm home environment, the blood pressure level does not go beyond normal values. In these cases, they talk about the so-called white coat hypertension, which develops most often in people with a labile nervous system. Often, such emotional fluctuations in blood pressure lead to overdiagnosis of hypertension and unjustified prescription of antihypertensive therapy, while the most effective remedy may be light sedative therapy. The white coat method of ambulatory 24-hour blood pressure monitoring helps diagnose hypertension.

The phenomenon of white coat hypertension has clinical significance and requires deeper study, since it is possible that such patients have a high risk of developing true hypertension and, accordingly, a higher risk of developing cardiovascular and renal pathology.

For prevention and treatment hypertension And type 2 diabetes mellitus at home, use the MED-MAG pulsating laser of the wrist and nose type.

Treatment of arterial hypertension in diabetes mellitus

The need for aggressive antihypertensive treatment in patients with diabetes is beyond doubt. However, diabetes mellitus, which is a disease with a complex combination of metabolic disorders and multiorgan pathology, poses a number of questions to doctors:

— At what blood pressure level should treatment begin?

— To what level is it safe to reduce systolic and diastolic blood pressure?

— What drugs are preferable to prescribe for diabetes mellitus, taking into account the systemic nature of the disease?

— What combinations of drugs are acceptable in the treatment of arterial hypertension in diabetes mellitus?

At what blood pressure level should treatment be started in patients with diabetes mellitus?

In 1997, the VI meeting of the United States Joint National Committee on the Diagnosis, Prevention and Treatment of Arterial Hypertension recognized that for patients with diabetes mellitus, the critical level of blood pressure for all age groups, above which treatment should be started, is systolic blood pressure > 130 mm Hg. and blood pressure >85 mm Hg. Even a slight excess of these values in patients with diabetes increases the risk of cardiovascular disasters by 35%. At the same time, it has been proven that stabilizing blood pressure at this level and below has a real organ-protective effect.

To what level is it safe to reduce diastolic blood pressure?

More recently, in 1997, an even larger study was completed, the purpose of which was to determine what level of blood pressure (<90, <85 или <80 мм рт.ст.) необходимо поддерживать для достижения наименьшей сердечно-сонсудистой заболеваемости и смертности. Из почти 19.000 больных, включенных в исследование, 1501 человек составляли больные сахарнным диабетом с АГ. В этом исследовании было показано, что оптинмальный уровень АД, при котором наблюдалось наименьшее число сердечно-сосудистых катастроф, соответствовал 83 мм рт.ст. Сниженние АД до этого уровня сопровождалось уменьшением риска развинтия сердечно-сосудистых заболевний на 30%, а у больных сахарным диабетом — почти на 50%. Даже более интенсивное снижение АД до 70 мм рт.ст. у больных сахарным диабетом сопровождалось сниженинем смертности этих больных от ИБС.

The question of the optimal level of blood pressure also arises when deciding on the progression of renal pathology. Previously, it was believed that at the stage of chronic renal failure, when most of the glomeruli are sclerotic, it is necessary to maintain higher levels of systemic blood pressure to ensure adequate renal perfusion and maintain residual filtration function. However, an analysis of the results of recent prospective studies showed that blood pressure values exceeding 120 and 80 mm Hg. even at the stage of chronic renal failure they only accelerate the progression of renal pathology. Consequently, both at the earliest stages of kidney damage and at the stage of chronic renal failure, to slow down the rate of progression of DN, it is necessary to maintain blood pressure at a level not exceeding 120 and 80 mm Hg.

Principles of combined antihypertensive therapy for diabetes mellitus

The course of arterial hypertension in diabetes mellitus, complicated by diabetic nephropathy, often becomes difficult to control. In 20-60% of patients, monotherapy with even the most powerful drugs is not able to stabilize blood pressure at the required level (130/85 mm Hg). In this case, to achieve the set goal, a combination of several antihypertensive drugs from different groups is indicated. It has been shown that in patients with severe renal failure (with serum creatinine >500 µmol/l), doctors are forced to resort to a combination of more than 4 antihypertensive drugs.

The most effective combinations of drugs in the treatment of arterial hypertension in diabetes mellitus include the combination of an ALP inhibitor and a diuretic, an ACE inhibitor and a calcium antagonist.

According to the results of multicenter studies, successful control of blood pressure at a level not exceeding 130/85 mmHg. allows you to avoid the rapid progression of vascular complications of diabetes and prolong the patient’s life by 15 - 20 years.

For prevention and treatment hypertension And type 2 diabetes mellitus at home, use the MED-MAG pulsating laser of the wrist and nose type.

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How to reduce high blood pressure in type 2 diabetes?

Greetings to all blog readers! As I promised yesterday, I am posting for you the second part of the Marlezon ballet. Just kidding, of course. The second part of the article is devoted to the problem of the combination of hypertension and diabetes mellitus.

For those who missed the last article, I will say that in it I described typical mistakes and attitudes regarding the treatment of diabetes, and also gave some simple, as the world, tips on non-drug ways to reduce high blood pressure in diabetes, the article is here.

Today we will talk about medications, which, unfortunately, you usually cannot do without. And since in most cases it is necessary to take blood pressure medications, let’s do it consciously, knowing what we are taking and why. In the end, it’s your health that you need first of all, and not the doctor or your neighbor on the site. So, take all your blood pressure medications out of your drawers, purses and boxes.

We will figure out what you drink, for what purpose and how this drug affects carbohydrate and lipid metabolism, because these are the indicators that play a role when prescribed to a patient with type 2 diabetes. In addition, I will show you what antihypertensive drugs can do besides their immediate “pressure-lowering” effect.

Before analyzing the groups of drugs, I want to draw your attention to this. Currently, there are many, many medications that reduce high blood pressure. Only the laziest pharmaceutical company does not release its medicine. Therefore, there can be a lot of trade names and, naturally, I cannot know them all by sight. The main thing for you is not the name of the drug, but its active ingredient.

On the box with the medicine, the trade name is written in large letters, and immediately below it in small print is the name of the active substance. This is how you need to evaluate your drug, and I will use these names and give examples of some trade names. If it is not indicated on the package, it will definitely be indicated in the annotation to the medicine at the very beginning, for example, the active substance is enalapril.

Groups of antihypertensive drugs

Among the drugs that lower blood pressure there are drugs for emergency one-time relief of blood pressure and for long-term daily use. I already talked about this in the previous article. I will not dwell in detail on the first group. You know them all. These are drugs whose duration of action does not exceed 6 hours. Basically quickly reduces high blood pressure:

captopril (Capoten, Alkadil, Angiopril-25, etc.)
nifedipine (Kordafen, Cordaflex, Cordipin, etc.)
clonidine (Clonidine)
anaprilin
andipal
etc.

We are more interested not in how to reduce already high blood pressure, but in how to prevent it from rising at all. And for this there are modern, and not so long-acting, long-acting drugs. I will list the main groups, and then I will tell you in more detail about each of them.

The groups of antihypertensive drugs for regular daily use are as follows (these names are also indicated in the description of the medication):

diuretics
beta blockers
angiotensin converting enzyme inhibitors (ACEIs)
Angiotensin II receptor blockers (ARBs)
calcium channel blockers (calcium antagonists)
alpha blockers
imidazoline receptor stimulants
renin blockers

As you can see, there are a lot of groups and the names are very complex and not clear. In short, each drug blocks or stimulates different receptors that are involved in regulating blood pressure. Since different people have different mechanisms for the development of hypertension, the point of application of the medicine will also be different.

Which one to choose so as not to make a mistake and not cause harm? The choice is not easy, because diabetes has some restrictions. Therefore, all selected drugs must meet the following requirements:

1. high activity with minimal side effects

2. no effect on blood sugar and lipid levels

3. the presence of a protective effect on the heart and kidneys (cardio- and nephroprotective effects)

Next, I will tell you in simple language how this or that drug works, and whether it can be used by patients with diabetes. At first I wanted to write in detail, but then I thought that you don’t need to know about research and experiments. Therefore, I will immediately write my conclusions and recommendations. And forgive me if medical terms come out somewhere, sometimes you can’t live without them. OK?

ACE inhibitors

ACE inhibitors (angiotensin-converting enzyme inhibitors or blockers) are the first choice drug for patients with hypertension and diabetes mellitus. This group of drugs blocks the enzyme that promotes the synthesis of angiotensin II, which constricts blood vessels and causes the adrenal glands to secrete the hormone aldosterone, which retains sodium and water. When taking ACE inhibitors, the blood vessels dilate, and excess sodium and water stop accumulating, resulting in lower blood pressure.

In other words, as soon as a person comes for the first time and is diagnosed with diabetes and hypertension, the first drug prescribed is ACE inhibitors. They are easy to distinguish among other drugs. All names of active substances in this group end in “-adj”.

For example:

Why this group? Because this group of antihypertensive drugs has a very pronounced nephroprotective effect, which persists regardless of the level of pressure reduction. They slow down the progression of kidney pathology (nephropathy) already at the stage of microalbuminuria, even if there is no high blood pressure. Therefore, I recommend that all patients undergo an annual microalbuminuria test, because this stage is still reversible. And if detected, I prescribe very small doses of an ACE inhibitor, even if the blood pressure is normal. Such doses do not lower blood pressure below normal; it is completely safe.

In addition, quinapril (Accupro) has an additional protective effect on the inner wall of blood vessels, thereby protecting it from the formation of atherosclerotic plaques and reducing the risk of developing heart attacks and strokes, i.e., it has a cardioprotective effect. ACE inhibitors do not affect carbohydrate and lipid metabolism and reduce tissue insulin resistance.

When treating with these drugs, it is imperative to follow a salt-free diet, that is, do not eat salty foods and do not add any additional salt.

When using inhibitors in patients with renal failure, constant monitoring of potassium levels is required, since these drugs have the ability to somewhat delay the excretion of potassium from the body.

And although the drugs in this group are so good, they are not suitable for everyone. Some people develop a severe cough soon after starting to take it, requiring complete discontinuation. Complete insensitivity to the drug is rarely observed. Patients with moderate hypertension (blood pressure up to 140/90 mm Hg) are on one drug; if the pressure is higher, then a drug from another group is added (see below).

ACE inhibitors begin to act rather slowly. After about 2 weeks, the dose of the drug taken reveals the full effect and, if the pressure has not returned to normal, then an increase in the dose is required and an assessment of effectiveness after 2 weeks. If it was still not possible to achieve the target blood pressure level (less than 130/80 mm Hg), then a drug from another group is added to this dose.

I recommend choosing original drugs rather than generics. The trade names indicated above are original drugs. They have approximately the same effectiveness; you can ask your cardiologist about the details. In addition, it is better to choose a drug with a single dose, i.e., a 24-hour effect. This way you won’t forget to take the pill, and no extra chemicals will enter your body.

Contraindications

2. pregnancy and lactation

Diuretics

In medicine, there are several types of diuretic drugs that affect different parts of the kidney tubules, and therefore their effect is slightly different. Diuretic drugs are not used as monotherapy, only as part of a combination therapy, otherwise the effect will be very low.

Most often used:

thiazide (hypothiazide)
loop (furosemide and lasix)
thiazide-like (indapamide)
potassium-sparing (veroshpiron)

Diuretics enhance the effect of the ACE inhibitor, so this is a very common combination for treating blood pressure among doctors. But even here there are some limitations, and they also have poor kidney protection. Subscribe to new blog articles. to receive them by email.

Thiazide diuretics(hypothiazide) should be prescribed with caution to patients with diabetes mellitus, because in large doses (50-100 mg/day) they can increase sugar and cholesterol levels. And also in the presence of renal failure (CKD), which is not uncommon for diabetes, they can inhibit the already weak kidney function. Therefore, in such patients, thiazide diuretics are not used, but others are used (see below). They are contraindicated for gout. A safe dose of hypothiazide for a diabetic is considered to be only 12.5 mg/day.

Loop diuretics are used less frequently because they greatly stimulate diuresis and remove potassium, which, if taken uncontrolled, can lead to hypokalemia and cardiac arrhythmias. But they work very well with an ACE inhibitor in patients with kidney failure because they improve kidney function. Can be taken for a short time when there is severe swelling. Of course, in this case potassium is replenished with additional drugs. Furosemide and Lasix do not affect blood sugar or lipid levels, but do not have protective properties on the kidneys.

Thiazide-like diuretics very often prescribed together with ACE inhibitors. And I welcome this combination because these diuretics have a mild diuretic effect, have little effect on potassium excretion, and do not affect kidney function or lipid glucose levels. In addition, indapamide has a nephroprotective effect at any stage of kidney damage. Personally, I prefer to prescribe a long-acting drug - Arifon-retard 2.5 mg 1 time in the morning.

Potassium-sparing drug – veroshpiron sometimes prescribed by doctors, but one must remember that it is contraindicated in case of renal failure, in which potassium accumulates in the body anyway. In this case, there will be the opposite, hyperkalemia, which can be fatal. For the treatment of hypertension in patients with diabetes, the use of veroshpiron is strictly not recommended.

Conclusion. the most optimal diuretic drug for a person with diabetes and hypertension is indapamide, and if there is chronic renal failure, it is better to use loop diuretics.

Angiotensin II receptor blockers (ARBs)

Another group of first-line blood pressure medications, like ACE inhibitors, are angiotensin II receptor blockers (ARBs). They can be prescribed immediately if high blood pressure is detected or if it is poorly tolerated instead of inhibitors, for example, if a cough occurs. According to the mechanism of action, they are slightly different from inhibitors, but the final effect is the same - a decrease in the activity of angiotensin II. The names are also easy to distinguish. All active ingredients end in “-sartan” or “-zartan”.

For example:

And again, I indicated the original drugs, and you can find generics yourself; now there are more and more of them. ARBs are as effective as ACE inhibitors. They also have a nephroprotective effect and can be prescribed to people with microalbuminuria and normal blood pressure. ARBs do not have a negative effect on carbohydrate and lipid metabolism, and also reduce insulin resistance.

But they still differ from ACE inhibitors. Angiotensin receptor blockers are able to reduce left ventricular hypertrophy, and do this with maximum efficiency compared to other groups of lowering drugs. That is why sartans, as they are also called, are prescribed for an increase in the size of the left ventricle, which often accompanies hypertension and heart failure.

It has been noted that ARBs are better tolerated by patients compared to ACE inhibitors. In case of renal failure, the drug is prescribed with caution. A preventive effect has been proven in terms of the development of diabetes mellitus in a patient with hypertension and impaired glucose tolerance.

Sartans combine well with diuretics, and if it is impossible to achieve the goal (blood pressure less than 130/80 mm Hg) in monotherapy, it is recommended to prescribe one of the diuretics, for example, indapamide.

Contraindications

1. bilateral renal artery stenosis

2. pregnancy and lactation

So, that's all for now. You have food for thought for today. And tomorrow you will find famous and controversial beta blockers, you will find out which drug is good for a combination of diabetes, hypertension and prostate adenoma, which calcium antagonist does not cause edema and much other useful information. Tomorrow I hope to completely close the topic of tandem treatment of hypertension and diabetes.

That’s all for me, but I don’t say goodbye, I say to everyone “See you tomorrow!”

Treatment of arterial hypertension in diabetes mellitus

Poteshkina N.G. Mirina E.Yu.

Sugar diabetes(DM) is the most common endocrine disease. The number of people suffering from this disease is constantly growing. Currently, diabetes and its complications, as a cause of mortality in the population, are in 2nd place, second only to cancer. Cardiovascular pathology, which previously occupied this line, moved to 3rd place, since in many cases it is a late macrovascular complication of diabetes.

30-40% of patients with type 1 diabetes and more than 70-80% of patients with type 2 diabetes experience premature disability and early death from cardiovascular complications. It has been established that an increase in diastolic blood pressure for every 6 mm Hg. increases the risk of developing IHD by 25%, and the risk of developing stroke by 40%.

With type 2 diabetes without concomitant risk, the risk of developing ischemic heart disease and stroke increases by 2-3 times, renal failure - by 15-20 times, blindness - by 10-20 times, gangrene - by 20 times. With a combination of diabetes and arterial hypertension(AH), the risk of these complications increases by another 2-3 times, even with satisfactory compensation of carbohydrate metabolism.

Thus, correction of hypertension is a task no less important than compensation of metabolic disorders, and should be carried out simultaneously with it.

In type 1 diabetes, the main pathogenetic link in the development of hypertension is the progression diabetic nephropathy, when the excretion of potassium in the urine decreases and at the same time its reabsorption by the renal tubules increases. As a result of an increase in sodium content in vascular cells, calcium ions accumulate in vascular cells, which ultimately leads to an increase in the sensitivity of vascular cell receptors to constrictive hormones (catecholamine, angiotensin II, endothelin I), which causes vasospasm and leads to increased total peripheral resistance (TPPR).

There is an opinion that the development of hypertension and diabetic nephropathy in type 1 diabetes is interconnected and is influenced by common genetic factors.

In type 2 diabetes, the main starting point for an increase in blood pressure is insulin resistance and compensatory hyperinsulinemia, which, like hypertension, usually precede the clinical manifestation of diabetes. In 1988, G. Reaven established a connection between the insensitivity of peripheral tissues to the action of insulin and such clinical manifestations as obesity, dyslipidemia, and impaired carbohydrate metabolism. As you know, the syndrome is called “metabolic”, “syndrome X”.

Metabolic syndrome (MS) combines a number of metabolic and clinical laboratory changes:

Abdominal obesity;

Insulin resistance;

Hyperinsulinemia;

Impaired glucose tolerance/type 2 diabetes;

- arterial hypertension;

Dyslipidemia;

Impaired hemostasis;

Hyperuricemia;

Microalbuminuria.

Based on the number of major risk factors for the development of coronary artery disease (abdominal obesity, impaired glucose tolerance or type 2 diabetes, dyslipidemia and hypertension), MS is called a deadly quartet.

One of the main components of MS and the pathogenesis of type 2 diabetes is insulin resistance - a violation of glucose utilization by the liver and peripheral tissues (liver and muscle tissue). As mentioned above, the compensatory mechanism for this condition is hyperinsulinemia, which ensures an increase in blood pressure as follows:

Insulin increases the activity of the sympathetic-adrenal system;

Insulin increases the reabsorption of sodium and fluid in the proximal tubules of the kidneys;

Insulin, as a mitogenic factor, increases the proliferation of vascular smooth muscle cells, which narrows their lumen;

Insulin blocks the activity of Na+-K+-ATPase and Ca2+-Mg2+-ATPase, thereby increasing the intracellular content of Na+ and Ca2+ and increasing the sensitivity of blood vessels to the effects of vasoconstrictors.

However, we should not forget about such a late complication of diabetes as the cardiovascular form of autonomic neuropathy.

In the presence of this severe complication, the most common complaint is dizziness when changing body position - orthostatic hypotension, which is a consequence of impaired vascular innervation and maintenance of their tone. This complication complicates both diagnosis and treatment AG.

Treatment arterial hypertension, as already noted, should be carried out simultaneously with glucose-lowering therapy. It is very important to convey to patients that treatment AH, like DM, is carried out continuously and for life. And the first point in treatment Hypertension, like any chronic disease, is by no means drug therapy. It is a known fact that up to 30% of hypertension is sodium-dependent, so table salt is completely excluded from the diet of such patients. Particular attention should be paid to the fact that our diet, as a rule, contains a lot of hidden salts (mayonnaise, salad dressings, cheeses, canned food), which should also be limited.

The next point to solve this problem is to reduce body weight in the presence of obesity. In obese patients with type 2 diabetes, hypertension or hyperlipidemia, a decrease in body weight of approximately 5% of initial weight leads to:

Improving diabetes compensation;

A decrease in blood pressure by 10 mm Hg;

Improving lipid profile;

Reducing the risk of premature death by 20%.

Weight loss is a difficult task for both the patient and the doctor, since the latter requires a lot of patience to explain to the patient the need for these non-drug measures, review his usual diet, choosing the optimal one, and consider options for regular (regularity is a prerequisite) physical activity. The patient needs understanding and patience in order to begin to apply all this in life.

What drugs for treatment Is hypertension preferable for diabetes? Of course, number one is ACE inhibitors or angiotensin II receptor type 1 antagonists. Until recently, it was believed that ACE inhibitors were preferable to prescribe for type 1 diabetes, given their pronounced nephroprotective effect, and it was preferable to start therapy with angiotensin II receptor blockers in people suffering from type 2 diabetes. In 2003, the expert committee of the All-Russian Scientific Society of Cardiologists in the 2nd revision of Russian recommendations for prevention, diagnosis and treatment arterial hypertension considered it appropriate to recommend both groups of drugs as the first line for the treatment of hypertension against the background diabetic nephropathy in any type of diabetes.

Given such low target blood pressure levels (130/80 mmHg), almost 100% of patients should receive combination therapy. What is better to combine with? If the patient has coronary heart disease or heart failure, then b-blockers.

Very often, refusal to take b-blockers is due to the fact that drugs in this group mask the symptoms of hypoglycemia. A study of more than 13,000 elderly patients with hypertension found no statistically significant change in the risk of hypoglycemia when using insulin or sulfonylurea with any class of antihypertensive drugs compared with patients not receiving antihypertensive therapy. In addition, the risk of serious hypoglycemia among patients taking beta-blockers was lower than among other classes of antihypertensive drugs. After 9 years, the UKPDS study found no differences in the number or severity of hypoglycaemic episodes between the atenolol and captopril groups. The effect of the highly selective b-blocker bisoprolol (Concor) on blood glucose levels in patients with concomitant type 2 diabetes has been studied, in particular, by H.U. Janka et al. After 2-week therapy with bisoprolol (Concor), blood glucose concentrations were assessed 2 hours after taking the drug or placebo, and no significant differences in changes in glucose levels were detected in the bisoprolol and placebo groups. The data obtained allowed the authors to conclude that during treatment with bisoprolol (Concor), hypoglycemia is not observed in patients with diabetes and no dose adjustment of oral antidiabetic agents is required. Concor is a metabolically neutral drug.

Recent studies show that the risk of cardiovascular complications after treatment with captopril and atenolol was virtually the same, although beta-blockers were thought to diabetes contraindicated. But b-blockers have their own application points in the pathogenesis of diabetes: ventricular arrhythmia, myocardial damage, and increased blood pressure. This is why b-blockers improve the prognosis for diabetes. A patient with diabetes and incipient myocardial ischemia has a prognosis of morbidity and mortality similar to a patient with post-infarction cardiosclerosis. If a diabetic patient has coronary artery disease, then the use of b-blockers is necessary. And the higher the selectivity of b-blockers, the fewer side effects there will be. That is why the highly selective b-blocker Concor has a number of advantages in patients with diabetes. The negative effect of b-blockers on lipid metabolism is also practically absent when bisoprolol (Concor) is prescribed. By increasing blood flow in the microcirculation system, bisoprolol (Concor) reduces tissue ischemia, indirectly affecting the improvement of glucose utilization. At the same time, there are all the positive effects and a significant reduction in the risk of cardiovascular complications.

Thus, we begin the treatment of hypertension in diabetes of any type with a complex of dietary and physical measures, immediately introducing drug therapy, which we begin with ACE inhibitors or angiotensin II receptor blockers, to the combination of which we always add a highly selective b-blocker such as Concor . As needed, calcium channel blockers and diuretics may also be included in the same combination.

However, a conversation about the treatment of hypertension in type 2 diabetes will be incomplete without mentioning the drugs with which, according to numerous studies, treatment of type 2 diabetes should begin - with biguanides, which reliably reduce insulin resistance, thereby reducing the risk of developing cardiovascular complications. At the same time, lipid metabolism is normalized: the level of triglycerides and low-density lipoproteins, the level of free fatty acids decreases, and the level of high-density lipoproteins increases.

Thus, the approach to the treatment of hypertension in diabetes should be multifactorial, using not only standard antihypertensive drugs, but also those drugs that affect the primary risk factors and trigger mechanisms - insulin resistance and hyperinsulinemia.

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