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Antihypertensive treatment. Antihypertensive therapy for hypertensive crisis. Antihypertensive drugs. Features of different groups of drugs

Drug treatment of hypertension is indicated for all patients with blood pressure higher than 160/100 mmHg. Art., and also when lifestyle modification measures have not led to normalization of blood pressure and it remains higher than 140/90 mm Hg. Art. There are a lot of drugs that lower blood pressure. Depending on their composition and mechanism of action, they are divided into groups and even subgroups.

These drugs are called antihypertensive or hypotensive drugs. We bring to your attention a review of drugs to lower blood pressure.

Principles of drug treatment of hypertension

Blood pressure-lowering medications for hypertension must be taken not in courses, but for life.

Before considering each group of drugs separately, let's talk briefly about the basic principles of drug treatment for essential hypertension, or hypertension.

Classification of antihypertensive drugs

Drugs used to lower blood pressure can be divided into 2 large groups:
I. First-line drugs. They are the drugs of choice in the treatment of hypertension. The vast majority of hypertensive patients are recommended to prescribe them. This group includes 5 more groups of drugs:

angiotensin-converting enzyme inhibitors (abbreviated as ACEIs);
diuretics, or diuretics;
angiotensin II receptor inhibitors;
β-blockers, or β-blockers;
calcium antagonists.

II. Second line drugs. For long-term treatment of essential hypertension, they are used only in certain classes of patients, for example, women, or people with low incomes who, for financial reasons, cannot afford first-line drugs. These drugs include:

α-blockers;
rauwolfia alkaloids;
Centrally acting α2-agonists;
direct acting vasodilators.

Let's consider each of these groups separately.

Angiotensin-converting enzyme inhibitors, or ACEIs

Group of the most effective antihypertensive drugs. A decrease in blood pressure when taking these medications occurs due to the dilation of blood vessels: their total peripheral resistance decreases, and therefore the pressure decreases. ACEIs have virtually no effect on cardiac output and heart rate, so they are widely used for concomitant chronic heart failure.

Already after taking the first dose of this group of drugs, the patient notices a decrease in blood pressure. When used for several weeks, the hypotensive effect increases and, having reached a maximum, stabilizes.

Adverse reactions to ACE inhibitors are quite rare and are manifested mainly by an obsessive dry cough, taste disturbance and signs of hyperkalemia (increased potassium levels in the blood). Hypersensitivity reactions to ACE inhibitors in the form of angioedema are rarely observed.

Since ACE inhibitors are eliminated primarily by the kidneys, if the patient is severely ill, the dose of these drugs should be reduced. Drugs of this group are contraindicated during pregnancy, in case of bilateral stenosis of the renal arteries, as well as in case of hyperkalemia.

The main representatives of the class of ACE inhibitors are:

enalapril (Enap, Berlipril, Renitek) - the daily dose of the drug ranges from 5-40 mg in 1-2 doses;
captopril - taken in a dose of 25-100 mg per day in 2-3 doses;
quinapril (Accupro) – daily dose is 10-80 mg in 1-2 doses;
lisinopril (Lopril, Diroton, Vitopril) – it is recommended to take 10-40 mg per day, the frequency of administration is 1-2 times;
moexipril (Moex) – 7.5-30 mg daily dose, frequency of administration – 1-2 times; It is worth noting that this drug is one of the ACE inhibitors recommended for use by persons with severe chronic renal failure;
perindopril (Prenesa, Prestarium) – daily dose is 5-10 mg in 1 dose;
ramipril (Tritace, Ampril, Hartil) – daily dose 2.5-20 mg in 1-2 doses;
spirapril (Quadropril) – taken in a dose of 6 mg once a day;
trandolapril (Hopten) – taken in a dose of 1-4 mg 1 time per day;
fosinopril (Fosicard) – take 10-20 mg 1-2 times a day.

Diuretics, or diuretics

Like ACE inhibitors, they are widely used in the treatment of hypertension. These drugs increase the volume of urine excreted, resulting in a decrease in the volume of circulating blood and extracellular fluid, a decrease in cardiac output, and dilation of blood vessels, all of which result in a decrease in blood pressure. It is worth noting that while taking diuretics, development is possible.

Diuretics are often used as part of combination therapy for hypertension: they remove excess water from the body, which is retained when taking many other antihypertensive drugs. They are contraindicated for.

Diuretics can also be divided into several groups.
1. Thiazide diuretics. They are most often used for antihypertensive purposes. Low dosages are generally recommended. They are ineffective in cases of severe renal failure, which is also a contraindication to their use. The most commonly used thiazide diuretic is hydrochlorothiazide (Hypothiazide). The daily dose of this drug is 12.5-50 mg, the frequency of administration is 1-2 times a day.
2. Thiazide-like diuretics. The most prominent representative of this group of drugs is indapamide (Indap, Arifon, Ravel-SR). It is usually taken at 1.25-2.5-5 mg once a day.
3. Loop diuretics. Drugs of this group do not play a significant role in the treatment of hypertension, however, in the case of concomitant or renal failure in a hypertensive patient, they are the drugs of choice. Often used in acute conditions. The main loop diuretics are:

furosemide (Lasix) - the daily dose of this drug ranges from 20 to 480 mg, depending on the severity of the disease, the frequency of administration is 4-6 times a day;
torasemide (Trifas, Torsid) – taken in a dose of 5-20 mg twice a day;
ethacrynic acid (Uregit) - daily dose ranges from 25-100 mg in two doses.

4. Potassium-sparing diuretics. They have a weak hypotensive effect and also remove a small amount of sodium from the body, preserving potassium. They are rarely used alone for the treatment of hypertension, more often in combination with drugs from other groups. Not applicable when. The most prominent representatives of this class are the following potassium-sparing diuretics:

spironolactone (Veroshpiron) – the daily dose of the drug is 25-100 mg, the frequency of administration is 3-4 times a day;
triamterene - take 25-75 mg 2 times a day.

Angiotensin II receptor inhibitors

The second name for drugs in this group is sartans. This is a relatively new class of antihypertensive drugs that are highly effective. Provide effective 24-hour blood pressure control when taking the drug once a day. Sartans do not have the most common side effect of ACE inhibitors - a dry hacking cough, therefore, those with intolerance to ACE inhibitors, as a rule, replace them with sartans. Drugs of this group are contraindicated during pregnancy, bilateral renal artery stenosis, and hyperkalemia.

The main representatives of sartans are:

irbesartan (Irbetan, Converium, Aprovel) – it is recommended to take 150-300 mg once a day;
candesartan (Candesar, Kasark) – taken in a dose of 8-32 g 1 time per day;
losartan (Lozap, Lorista) – daily dose of the drug 50-100 mg in 1 dose;
telmisartan (Praytor, Micardis) – recommended daily dose of 20-80 mg, in 1 dose;
valsartan (Vazar, Diovan, Valsacor) - taken at a dose of 80-320 mg per day for 1 dose.

β-blockers

Beta blockers are especially indicated for people who have hypertension combined with tachycardia.

They reduce blood pressure due to a blocking effect on β-adrenergic receptors: cardiac output and renin activity in the blood plasma decrease. Especially indicated for arterial hypertension, combined with angina pectoris and certain types. Because one of the effects of beta blockers is to decrease heart rate, these drugs are contraindicated in bradycardia.
Drugs in this class are divided into cardioselective and non-cardioselective.

Cardioselective β-blockers act exclusively on receptors of the heart and blood vessels, and do not affect other organs and systems.
Drugs in this class include:

atenolol (Atenol, Tenolol, Tenobene) - the daily dose of this drug is 25-100 mg, the frequency of administration is twice a day;
betaxolol (Betak, Betakor, Lokren) – taken in a dose of 5-40 mg once a day;
bisoprolol (Concor, Coronal, Biprol, Bicard) - taken in a dose of 2.5-20 mg per day at a time;
metoprolol (Betalok, Corvitol, Egilok) - the recommended daily dose of the drug is 50-200 mg in 1-3 doses;
nebivolol (Nebilet, Nebilong, Nebil) – take 5-10 mg once a day;
celiprolol (Celiprol) – take 200-400 mg once a day.

Cardiononselective β-blockers affect receptors not only of the heart, but also of other internal organs, therefore they are contraindicated in a number of pathological conditions, such as chronic obstructive pulmonary disease, intermittent claudication.

The most commonly used representatives of this class of drugs are:

propranolol (Anaprilin) – taken 40-240 mg per day in 1-3 doses;
carvedilol (Coriol, Medocardil) - the daily dose of the drug is 12.5-50 mg, the frequency of administration is 1-2 times a day;
labetalol (Abetol, Labetol) – it is recommended to take 200-1200 mg per day, dividing the dose into 2 doses.

Calcium antagonists

They reduce blood pressure well, but due to their mechanisms of action they can have very serious side effects.

1. Phenylalkylamine derivatives. Verapamil (Finoptin, Isoptin, Veratard) – it is recommended to take a dose of 120-480 mg per day in 1-2 doses; may cause bradycardia and atrioventricular block.
2. Benzothiazepine derivatives. Diltiazem (Aldizem, Diacordin) - its daily dose is equal to that of verapamil and is 120-480 mg in 1-2 doses; causes bradycardia and AV block.
3. Dihydropyridine derivatives. They have a pronounced vasodilator effect. May cause an acceleration of the heart rate. The main representatives of this class of calcium antigonists are as follows:

amlodipine (Azomex, Amlo, Agen, Norvasc) - the daily dose of the drug is 2.5-10 mg in one dose;
lacidipine (Latsipil) – take 2-4 mg per day at a time;
lercanidipine (Zanidip, Lerkamen) – take 10-20 mg once a day;
nifedipine (retard - long-acting - forms: Corinfar retard, Nifecard-XL, Nicardia) - take 20-120 mg per day at a time;
felodipine (Felodip) – the daily dose of the drug is 2.5-10 mg in one dose.

Combination drugs

Often, first-line antihypertensive drugs are included in combination drugs. As a rule, they contain 2, less often 3, active substances belonging to different classes, which means they lower blood pressure in different ways.

Here are examples of such drugs:

Triampur – hydrochlorothiazide + triamterene;
Tonorma – atenolol + chlorthalidone + nifedipine;
Captopress – captopril + hydrochlorothiazide;
Enap-N – enalapril + hydrochlorothiazide;
Liprazide – lisinopril + hydrochlorothiazide;
Vazar-N – valsartan + hydrochlorothiazide;
Ziac – bisoprolol + hydrochlorothiazide;
Bi-Prestarium – amlodipine + perindopril.

α-blockers

Currently, they are used relatively rarely, usually in combination with first-line drugs. The main very serious disadvantage of drugs in this group is that long-term use of them increases the risk of developing heart failure, acute cerebrovascular accidents (stroke) and sudden death. However, α-blockers also have a positive property that distinguishes them from other drugs: they improve carbohydrate and lipid metabolism, which is why they are the drugs of choice for the treatment of hypertension in people with concomitant diabetes mellitus and dyslipidemia.

The main representatives of drugs in this class are:

prazosin - take it 1-20 mg 2-4 times a day; This drug is characterized by the effect of the 1st dose: a sharp decrease in blood pressure after the first dose;
doxazosin (Cardura, Zoxon) – recommended dose – 1-16 mg 1 time per day;
terazosin (Cornam, Alfater) – 1-20 mg per day for 1 dose;
phentolamine – 5-20 mg per day.

Rauwolfia preparations

They have a good hypotensive effect (develops after about 1 week of regular use of the drug), but have many side effects, such as drowsiness, depression, nightmares, insomnia, dry mouth, anxiety, bradycardia, bronchospasm, weakened potency in men, vomiting , allergic reactions, . Of course, these drugs are cheap, which is why many elderly hypertensive patients continue to take them. However, among the 1st line drugs there are also options that are financially accessible to most patients: they should be taken if possible, and rauwolfia drugs should be gradually abandoned. These drugs are contraindicated in cases of severe epilepsy, parkinsonism, depression, bradycardia and severe heart failure.
Representatives of rauwolfia preparations are:

reserpine - recommended to take 0.05-0.1-0.5 mg 2-3 times a day;
raunatin - taken according to the scheme, starting with 1 tablet (2 mg) per day at night, increasing the dose by 1 tablet every day, bringing it to 4-6 tablets per day.

Combinations of these drugs are most often used:

Adelphan (reserpine + hydralazine + hydrochlorothiazide);
Sinepres (reserpine + hydralazine + hydrochlorothiazide + potassium chloride);
Neocristepine (reserpine + dihydroergocristine + chlorthalidone).

Central α2 receptor agonists

Drugs in this group reduce blood pressure by acting on the central nervous system, reducing sympathetic hyperactivity. They can cause quite serious side effects, but in certain clinical situations they are irreplaceable, for example, the drug methyldopa for arterial hypertension in pregnant women. Side effects of central α2-receptor agonists are due to their effect on the central nervous system - drowsiness, decreased attention and reaction speed, lethargy, depression, weakness, fatigue, headache.
The main representatives of drugs in this group are:

Clonidine (Clonidine) – used 0.75-1.5 mg 2-4 times a day;
Methyldopa (Dopegit) – single dose is 250-3000 mg, frequency of administration – 2-3 times a day; drug of choice for the treatment of arterial hypertension in pregnant women.

Direct acting vasodilators

They have a mild hypotensive effect due to moderate vasodilation. More effective in injection form than when taken orally. The main disadvantage of these drugs is that they cause “steal” syndrome - roughly speaking, they disrupt the blood supply to the brain. This limits their use in people suffering from atherosclerosis, and this is the majority of patients with high blood pressure.
Representatives of this group of drugs are:

bendazole (Dibazol) - 0.02-0.05 g is used orally 2-3 times a day; more often used intramuscularly and intravenously to quickly reduce blood pressure - 2-4 ml of a 1% solution 2-4 times a day;
hydralazine (Apressin) - initial dose - 10-25 mg 2-4 times a day, average therapeutic dose - 25-50 g per day in 4 divided doses.

Medicines for the treatment of hypertensive crises

In order to treat uncomplicated cases, it is recommended to reduce the pressure not immediately, but gradually, over 1-2 days. Based on this, drugs are prescribed in tablet form.

Nifedipine - administered orally or sublingually (this method of administration is equivalent in effectiveness to intravenous administration) 5-20 mg; when taken orally, the effect occurs within 15-20 minutes, while when taken sublingually, the effect occurs within 5-10 minutes; possible side effects such as headache, severe hypotension, tachycardia, redness of the facial skin, symptoms of angina pectoris;
Captopril - used 6.25-50 mg sublingually; begins to act within 20-60 minutes;
Clonidine (Clonidine) – taken orally at 0.075-0.3 mg; the effect is observed within half an hour or an hour; Side effects include sedation and dry mouth; Caution should be exercised when using this drug in patients with;
Nitroglycerin - recommended dose - 0.8-2.4 mg sublingually (under the tongue); The hypotensive effect occurs quickly - within 5-10 minutes.

When treating complicated hypertensive crises, the patient is prescribed intravenous infusions of drugs. At the same time, blood pressure is constantly monitored. Most drugs used for this purpose begin to act within a few minutes after administration. Typically, the following medications are used:

Since complicated hypertensive crises are often accompanied by fluid retention in the body, treatment should begin with intravenous jet administration of a diuretic - furosemide or torsemide at a dose of 20-120 mg. If the crisis is accompanied by increased urination or severe vomiting, diuretics are not indicated.
In Ukraine and Russia, during a hypertensive crisis, drugs such as magnesium sulfate (popularly known as Magnesia), papaverine, dibazol, aminophylline and the like are often administered. Most of them do not have the desired effect, lowering blood pressure to certain numbers, but, on the contrary, lead to rebound hypertension: increased blood pressure.

Which doctor to contact

Complicated hypertensive crises require infusion of blood pressure-lowering drugs.

To prescribe antihypertensive therapy, you must consult a physician. If the disease is discovered for the first time or is difficult to treat, the physician may refer the patient to a cardiologist. Additionally, all patients with hypertension are examined by a neurologist and ophthalmologist to exclude damage to these organs, and an ultrasound of the kidneys is performed to exclude renovascular or renal secondary hypertension.

β-Adrenergic blockers.

Diuretics (saluretics).

Calcium antagonists.

ACE inhibitors.

Angiotensin II receptor antagonists.

Direct vasodilators.

α-Adrenergic blockers.

Centrally acting α2-agonists.

Sympatholytics.

Potassium channel activators.

Vasoactive prostaglandins and stimulators of prostacyclin synthesis.

The main groups of antihypertensive drugs are currently considered to be the first 4 groups: beta-blockers, diuretics, calcium antagonists, ACE inhibitors. When choosing antihypertensive drugs, the ability of the drugs to influence left ventricular hypertrophy, quality of life, as well as the ability of the drugs to affect the level of atherogenic lipoproteins in the blood are taken into account. The age of the patients and the severity of concomitant ischemic heart disease should also be taken into account.

Treatment with β-blockers

Non-cardioselective beta blockers

Propranolol (anaprilin, inderal, obzidan) - non-cardioselective beta-blocker without intrinsic sympathomimetic activity. It is prescribed to patients with arterial hypertension initially at 40 mg 2 times a day; a decrease in blood pressure is possible on the 5-7th day of treatment. In the absence of a hypotensive effect, every 5 days you can increase the daily dose by 20 mg and bring it to the individual effective one. It can range from 80 to 320 mg (i.e. 80 mg 4 times a day). After achieving the effect, the dose is gradually reduced and switched to a maintenance dose, which is usually 120 mg per day (in 2 divided doses). Propranolol extended-release capsules are prescribed once a day.

Nadolol (korgard) - non-cardioselective beta-blocker of extended action without internal sympathomimetic activity and membrane stabilizing effect. The duration of action of the drug is about 20-24 hours, so it can be taken once a day. Treatment begins with taking 40 mg of the drug once a day, then you can increase the daily dose by 40 mg every week and bring it up to 240 mg (less often - 320 mg).

Trazicore (oxprenolol) - a non-cardioselective beta-blocker with intrinsic sympathomimetic activity, prescribed 2 times a day. Available in tablets with a regular duration of action of 20 mg and extended action of 80 mg. Treatment begins with a daily dose of 40-60 mg (in 2 doses), followed by an increase to 160-240 mg

Cardioselective beta blockers

Cardioselective beta-blockers selectively block beta1-adrenergic receptors of the myocardium and have almost no effect on beta2-adrenergic receptors of the bronchi, do not cause vasoconstriction of skeletal muscles, do not impair blood flow in the extremities, have little effect on carbohydrate metabolism and have a less pronounced negative effect on lipid metabolism.

Atenolol - a cardioselective beta-blocker without internal sympathomimetic activity, devoid of membrane stabilizing effect. At the beginning of treatment, a daily dose of 50 mg is prescribed (in 1 or 2 doses). In the absence of a hypotensive effect, the daily dose can be increased after 2 weeks to 200 mg. The drug has a prolonged effect and can be taken 1-2 times a day.

Tenoric - a combination drug containing 0.1 g of atenolol and 0.025 g of the diuretic chlorthalidone. Tenorik is prescribed 1-2 tablets 1-2 times a day.

Metoprolol (Spesicor, betaxolol) is a cardioselective beta-blocker without intrinsic sympathomimetic activity. The drug acts for about 12 hours, is prescribed 100 mg once a day or 50 mg 2 times a day. After 1 week, the dose can be increased to 100 mg 2 times a day. The maximum daily dose with a gradual increase is 450 mg.

Betalok Durules - metoprolol extended release. Available in tablets of 0.2 g. Treatment begins with a dose of 50 mg once a day and gradually increases the dose to 100 mg. In the absence of a hypotensive effect, the daily dose is increased to 200 mg.

Cordanum (talinolol) - a cardioselective beta-blocker with intrinsic sympathomimetic activity. Treatment begins with taking 50 mg of the drug 3 times a day, then, if necessary, the daily dose is increased to 400-600 mg (in 3 doses).

Betaxolol (locrene) - long-acting beta-blocker with high cardioselectivity. The hypotensive effect of the drug lasts for 24 hours, so it can be prescribed once a day. The effect of betaxolol begins to appear after 2 weeks, and reaches its maximum after 4 weeks. Treatment begins with a dose of 10 mg per day. If the hypotensive effect is insufficient, after 2 weeks from the start of treatment, the dose is increased to 20 mg per day (average therapeutic dose), and, if necessary, gradually to 30 and even 40 mg per day.

Bisoprolol - long-acting cardioselective beta-blocker. The drug is prescribed 1 tablet 1 time per day, in the morning.

Beta blockers With vasodilating properties

For the treatment of patients with arterial hypertension, it is advisable to use beta-blockers that have vasodilating properties.

Beta blockers with vasodilating properties include:

non-cardioselective (pindolol, dilevalol, labetolol, niprandilol, proxodolol, carteolol);

cardioselective (carvedilol, prisidilol, celiprolol, bevantolol).

Carvedilol (dilatrend) - a vasodilating cardioselective beta-blocker, prescribed in a daily dose of 25-100 mg (in 1-2 doses).

Labetolol (Trandat, Albetol, Normodin) - non-cardioselective vasodilating beta-blocker, used in a daily dose of 200-1200 mg (in 2-4 doses). It has intrinsic sympathomimetic activity and has almost no effect on lipid levels.

Bevantolol - long-acting cardioselective vasodilating beta-blocker without intrinsic sympathomimetic activity. Prescribed 100 mg 1 time per day. If the hypotensive effect is insufficient, the daily dose can be increased to 600 mg (in 1-2 doses).

Side effects of beta blockers

Indications for long-term monotherapy of hypertension with beta-blockers and factors influencing the choice of drug

Arterial hypertension with the presence of left ventricular myocardial hypertrophy; Beta blockers reverse the development of left ventricular hypertrophy and thereby reduce the risk of sudden death.

Arterial hypertension in young patients who, as a rule, lead an active lifestyle. In such patients, an increase in the tone of the sympathetic nervous system and plasma renin activity is usually detected. The volume of circulating blood is not changed or even reduced. Beta-blockers reduce sympathetic activity, tachycardia, and normalize blood pressure. However, it should be borne in mind that beta-blockers adversely affect high-density lipoproteins, can cause sexual dysfunction and interfere with sports activities, as they reduce cardiac output.

Combination of arterial hypertension with angina pectoris. Beta-blockers have an antianginal effect. In this case, non-selective adrenergic blockers are preferable to prescribe to non-smoking patients with arterial hypertension, while in smokers, selective adrenergic blockers (metoprolol or atenolol) should apparently be given preference.

Long-term treatment of patients with arterial hypertension who have suffered transmural myocardial infarction. According to the results of controlled studies, in this situation, adrenergic blockers without intrinsic sympathomimetic activity (propranolol, nadolol, sotalol, timolol, atenolol) should be used for at least 1-3 years, regardless of the presence or absence of angina.

Arterial hypertension in combination with cardiac arrhythmias, primarily supraventricular, as well as sinus tachycardia.

In patients with arterial hypertension in combination with dyslipidemia, especially in young people, preference should be given to cardioselective adrenergic blockers, as well as drugs with internal sympathomimetic activity or vasodilating effects.

When arterial hypertension is combined with diabetes mellitus, non-cardioselective adrenergic blockers, which can disrupt carbohydrate metabolism, should not be prescribed. Selective adrenergic blockers (atenolol, acebutalol, metoprolol, talindol) or adrenergic blockers with pronounced internal sympathomimetic activity (pindolol) have the least effect on carbohydrate metabolism and insulin secretion.

In patients with arterial hypertension and liver dysfunction, lower doses of lipophilic adrenergic blockers (propranolol, metoprolol) should be used than under normal conditions, or hydrophilic drugs (nadolol, atenolol, etc.) that are not metabolized in the liver should be prescribed.

When arterial hypertension is combined with impaired renal function, the most suitable drug is the non-cardioselective adrenergic blocker nadolol, which does not change renal blood flow and glomerular filtration rate or even increases them, despite a decrease in cardiac output and mean blood pressure. Other non-cardioselective adrenergic blockers reduce renal blood flow due to the fact that they reduce cardiac output. Cardioselective adrenergic blockers and drugs with intrinsic sympathomimetic activity worsen renal function.

Treatment with diuretics

Diuretics have been used for many years not only as diuretics, but also to lower blood pressure.

The following groups of diuretic drugs are used to treat arterial hypertension:

thiazide and thiazide-like;

loop;

potassium-sparing;

uricosuric;

with vasodilating properties.

Thiazide and thiazide-like diuretics

Thiazide diuretics are most often used in patients with mild and moderate arterial hypertension. When treated with these drugs, in the first 2-3 days, a large natriuresis develops, which promotes the removal of large amounts of water from the body, which leads to a decrease in blood volume, a decrease in blood flow to the heart and, consequently, cardiac output. Thiazide diuretics are ineffective if the glomerular filtration rate is less than 25 ml/min. In these cases, stronger loop diuretics should be used.

Hydrochlorothiazide (hypothiazide, dihydrochlorothiazide, esidrex) - for high arterial hypertension, treatment with hydrochlorothiazide begins with a dose of 50-100 mg 1 time per day in the morning or 50 mg in 2 doses in the first half of the day, for mild and moderate hypertension - with a dose of 25 mg 1 time in the morning. The maintenance dose for long-term use is 25-50 mg in 1 dose (sometimes the daily dose is 50 mg in 2 doses).

While taking hypothiazide and other thiazide diuretics, it is necessary to adhere to a hyposodium and potassium-enriched diet. Following such a diet requires the use of smaller doses of drugs, therefore, the likelihood of side effects and their severity are reduced.

Korzid - a combination drug containing in 1 tablet 5 mg of bendroflumetazide and 40 or 80 mg of the non-selective adrenergic blocker nadolol.

Chlorothiazide (diuril) - the hypotensive effect develops several days after administration, the diuretic effect - after 2 hours. Treatment begins with a dose of 250 mg per day (in 1 dose), in the absence of a hypotensive effect, the dose is increased to 500 mg per day in 1 dose or 1000 mg per day in 2 doses.

When treated with thiazide diuretics, the following may develop: side effects:

hypokalemia (manifested by muscle weakness, paresthesia, sometimes muscle cramps, nausea, vomiting, extrasystole, decreased potassium levels in the blood;

hyponatremia and hypochloremia (main manifestations: nausea, vomiting, severe weakness, decreased levels of sodium and chlorides in the blood);

hypomagnesemia (the main clinical signs are muscle weakness, sometimes muscle twitching, vomiting);

hypercalcemia (rarely develops);

hyperuricemia;

hyperglycemia (its development is directly dependent on the dose of hypothiazide and the duration of its administration; cessation of treatment with hypothiazide can restore glucose tolerance, but not completely in some patients; adding potassium salts to treatment with hypothiazide can reduce the severity of hyperglycemia or even eliminate it. It has been established that the combination of hypothiazide with ACE inhibitors has a beneficial effect, preventing a decrease in carbohydrate tolerance);

increased levels of cholesterol and beta lipoproteins in the blood. In recent years, it has been found that hydrochlorothiazide violates carbohydrate tolerance and increases blood cholesterol and triglycerides only during the first two months of regular use of these drugs. In the future, with continued treatment, normalization of these indicators is possible;

Due to the relatively high frequency of side effects, many experts believe that monotherapy with hypothiazide and other thiazide compounds is not always advisable.

From thiazide-like diuretics The most commonly used drugs are the following.

Chlorthalidone (hygroton, oxodoline) - after oral administration, the diuretic effect begins after 3 hours and lasts up to 2-3 days. In contrast to hypothiazide, hypokalemia is observed less frequently during treatment with chlorthalidone. The drug is used in a daily dose of 25-50 mg.

Klopamide (brinaldix) - in a daily dose of 20-60 mg helps reduce systolic blood pressure by 30 mm Hg. Art., diastolic blood pressure - by 10 mm Hg. Art., the most pronounced hypotensive effect occurs after 1 month.

Loop diuretics

Loop diuretics act primarily at the level of the ascending limb of the loop of Henle. By inhibiting sodium reabsorption, they cause the most powerful diuretic effect, depending on the dose. At the same time, the reabsorption of potassium, calcium and magnesium is inhibited.

The following loop diuretics are known: furosemide (Lasix), ethacrynic acid (edecrin, uregit), bumetanide (Bumex).

Typically, loop diuretics are used in patients with arterial hypertension who are resistant to thiazide diuretics, to relieve hypertensive crises, and in severe renal failure.

The most commonly used loop diuretics are furosemide and ethacrynic acid.

Furosemide

When taken orally, the initial dose of furosemide is 40 mg 2 times a day, but in many patients the initial dose may be 20 mg. If necessary, the daily dose is gradually increased, but the maximum daily dose should be no more than 360 mg (in 2 doses). For hypertensive crises accompanied by pulmonary edema, as well as for acute renal failure, the initial dose is 100-200 mg intravenously. In case of stable hypertension, a dose of 40-80 mg is used for intravenous administration.

Furosemide is the drug of choice in the treatment of patients with impaired renal function (glomerular filtration rate less than 25 ml/min).

Ethacrynic acid (uregit) - Currently, ethacrynic acid is rarely used for the treatment of arterial hypertension.

The most common side effects of loop diuretics are: hypovolemia, hypokalemia, hyperuricemia; high doses may have ototoxic effects, especially in patients with renal failure. Loop diuretics may also have an adverse effect on carbohydrate and lipid metabolism.

Potassium-sparing diuretics

Potassium-sparing diuretics have a weak diuretic effect, but they reduce the excretion of potassium in the urine due to a decrease in its secretion into the lumen of the tubules. These drugs also have a hypotensive effect. The most commonly used potassium-sparing agents are:

spironolactone (veroshpiron, aldactone);

triamterene (pterophen);

amiloride

Spironolactone (veroshpiron, aldactone) - Available in tablets of 25, 50 and 100 mg.

The use of spironolactone in hypertension is justified by the fact that it has a hypotensive effect, reduces fibrosis in the myocardium and retains potassium in the body, preventing hypokalemia during treatment with diuretics.

When using spironolactone, it is recommended to start treatment with a daily dose of 50-100 mg (in 1 or 2 doses) for at least 2 weeks, then gradually increase the daily dose to 200 mg at 2-week intervals. The maximum daily dose is 400 mg.

Spironolactone does not cause hyperglycemia, hyperuricemia and does not have a negative effect on lipid metabolism (does not increase cholesterol and triglycerides in the blood), therefore it can be prescribed to those patients in whom thiazide diuretics cause these side effects.

TO side effects spironolactone include:

gastrointestinal disorders;

drowsiness;

Contraindications to prescribe spironolactone:

renal failure;

increased levels of creatinine or urea nitrogen in the blood;

hyperkalemia;
taking potassium supplements or potassium-sparing agents;
lactation.

Triamterene - available in capsules of 50 and 100 mg, as well as in the form of fixed combination drugs of the following composition:

pills triampur compositum(25 mg triamterene and 12.5 mg hydrochlorothiazide);

capsules diazide(50 mg triamterene and 25 mg hydrochlorothiazide);

tablets m akszid(75 mg triamterene and 50 mg hydrochlorothiazide).

The hypotensive effect of triamterene is weak, but its potassium-retaining effect is significant. As a rule, the drug is prescribed in combination with hydrochlorothiazide or furosemide. For antihypertensive purposes, triampur compositum is most often used, 1-2 tablets per dose 1-2 times a day.

Contraindications to the use of triamterene :

hyperkalemia;

severe liver failure;

simultaneous use of potassium supplements or potassium-sparing agents.

Diuretics with vasodilating properties

Indapamide hemihydrate (ariphone) - available in tablets of 1.25 and 2.5 mg, is a sulfonamide diuretic, specially created for the treatment of arterial hypertension.

Indapamide does not have a negative effect on lipid and carbohydrate metabolism, it can cause the development of hypokalemia and slightly increase the level of uric acid in the blood.

It is recommended to use the drug in a dose of 2.5 mg 1 time per day for any severity of hypertension; after 1-2 months the dose can be increased to 5 mg per day. Contraindicated in case of liver and kidney failure.

The hypotensive effect of indapamide is enhanced when combined with beta-blockers, ACE inhibitors, and methyldopa.

Indications for the predominant use of diuretics V as antihypertensive drugs

As stated above, diuretics do not reduce the severity of myocardial hypertrophy, do not significantly improve quality of life, and have an adverse effect on lipid and carbohydrate metabolism. In this regard, diuretics are most often used as a second drug in combination with other antihypertensive drugs.

The main indications for prescribing diuretics for arterial hypertension are:

volume-dependent hyporenin variant of hypertension, which is often found in women in the pre- and menopausal periods. It is characterized by clinical symptoms of fluid retention (tendency to edema, increased blood pressure following intake of excess water and salt, periodic oliguria, headaches in the occipital region), low renin levels in the blood;

high stable arterial hypertension, since it is accompanied by sodium and water retention that is not caused by cardiac failure; long-term use of diuretics leads to a quasodilating effect;

a combination of arterial hypertension with congestive heart failure, obstructive bronchial diseases (in this situation, beta-blockers are contraindicated), diseases of peripheral arteries;

combination of arterial hypertension with renal failure (except for potassium-sparing diuretics).

Treatment with calcium antagonists

Calcium antagonists have the following mechanisms of action:

block slow calcium channels and the flow of calcium into smooth muscle cells, due to which arteries and arterioles relax, total peripheral resistance decreases and a hypotensive effect is manifested;

increase renal blood flow without changing or increasing glomerular filtration;

reduce sodium reabsorption in the renal tubules, which leads to increased sodium excretion (natriuretic effect) without significant loss of potassium and hypokalemia;

reduce platelet aggregation by reducing the production of thromboxane and increasing the production of prostacyclin, which reduces platelet aggregation and dilates blood vessels;

reduce the degree of left ventricular myocardial hypertrophy, which reduces the risk of developing fatal cardiac arrhythmias;

verapamil and diltiazem have an antiarrhythmic effect and are the drugs of choice for stopping paroxysmal supraventricular tachycardia, as well as for the treatment of supraventricular extrasystoles that occur in patients with arterial hypertension;

have angioprotective, antiatherogenic effects, prevent the deposition of cholesterol and calcium into the vessel wall.

Calcium antagonists do not change the plasma lipid profile, tolerance to carbohydrates, do not increase the level of uric acid in the blood, do not impair sexual function in men, do not impair bronchial conduction, do not reduce physical performance, as they do not aggravate muscle weakness.

First generation calcium antagonists

The main first generation calcium antagonists are:

dihydropyridine derivative nifedipine;

phenylalkylamine derivative verapamil;

benzothiazepine derivative diltiazem.

Nifedipine

Nifedipine is available in the following dosage forms:

conventional dosage forms: adalat, corinfar, cordafen, procardia, nifedipine in 10 mg tablets; the duration of action of these forms is 4-7 hours;

prolonged dosage forms - adalat retard, nifedipine SS in tablets and capsules of 20, 30, 60 and 90 mg. The duration of the hypotensive effect of these forms is 24 hours.

Nifedipine is the most powerful short-acting calcium antagonist and has a pronounced antianginal and hypotensive effect.

To relieve a hypertensive crisis, short-acting capsules or tablets, pre-chewed, are taken under the tongue. The hypotensive effect occurs within 1-5 minutes.

For the regular treatment of arterial hypertension, long-acting nifedipine is used - slow-release tablets and capsules and very prolonged-release tablets, they are prescribed 20-30 mg 1 time per day; with an interval of 7-14 days, the dose can be gradually increased to 60-90 mg 1 time per day; extended-release dosage forms must be swallowed whole, without chewing; the maximum permissible daily dose is 120 mg.

The most significant side effects nifedipine are:

headache;

facial redness;

pastiness on the ankles and legs;

tachycardia;

increased frequency of angina attacks or painless myocardial ischemia (“steal syndrome”);

decreased myocardial contractility.

Basic contraindications to treatment with nifedipine: aortic stenosis, hypertrophic cardiomyopathy, decreased myocardial contractility, unstable angina and myocardial infarction.

Verapamil

Verapamil is available in the following dosage forms:

conventional dosage forms: verapamil, isoptin, finoptin in tablets, dragees and capsules of 40 and 80 mg;

extended forms: tablets of 120 and 240 mg, capsules of 180 mg;

ampoules of 2 ml of 0.25% solution (5 mg of substance per ampoule).

For the treatment of arterial hypertension, the drug is used as follows:

a) in conventional dosage forms - the initial dose is 80 mg 3 times a day; in elderly patients, as well as in people with low body weight, with bradycardia - 40 mg 3 times a day. During the first 3 months, the effect of verapamil may increase. The maximum daily dose for arterial hypertension is 360-480 mg;

b) extended forms of verapamil - the initial dose is 120-180 mg 1 time per day, then after a week you can increase the dose to 240 mg 1 time per day; then, if necessary, you can increase the dose to 180 mg 2 times a day (morning and evening) or 240 mg in the morning and 120 mg in the evening every 12 hours.

Main side effects verapamil are:

development of bradycardia and slowing of atrioventricular conduction;

decreased myocardial contractility;

Verapamil promotes the development of glycoside intoxication, as it reduces the clearance of cardiac glycosides. Therefore, when treating with verapamil, the dose of cardiac glycosides is reduced by.

Basic contraindications to treatment with verapamil:

atrioventricular block;

severe bradycardia;

sick sinus syndrome;

Atrial fibrillation in patients with additional conduction pathways;

Heart failure.

Diltiazem

Diltiazem is available in the following dosage forms:

conventional dosage forms: diltiazem, dilzem, cardizem, cardil in tablets of 30, 60, 90 and 120 mg;

prolonged dosage forms in capsules of 60, 90 and 120 mg with slow release of the drug;

ampoules for intravenous administration.

Diltiazem is used to treat hypertension as follows:

a) conventional dosage forms (capsule tablets) - start with a dose of 30 mg 3 times a day, then the daily dose is gradually increased to 360 mg (in 3 doses);

b) long-acting dosage forms (slow release) - start with a daily dose of 120 mg (in 2 divided doses), then the daily dose can be increased to 360 mg (in 2 divided doses);

c) very prolonged forms - start with a dose of 180 mg 1 time per day, then the daily dose can be gradually increased to 360 mg (with a single dose).

Diltiazem has the same side effects as verapamil, but its negative chrono- and inotropic effects are less pronounced.

Second generation calcium antagonists

Nicardipine (cardin) - compared to nifedipine, it has a more selective effect on the coronary and peripheral arteries.

The drug has a very weak negative inotropic and chronotropic effect and slightly slows down intraventricular conduction. The hypotensive effect of nicardipine is similar to the hypotensive effect of other calcium antagonists.

Nicardipine is available in extended-release capsules and is prescribed initially at 30 mg 2 times a day, then the dose is gradually increased to 60 mg 2 times a day.

Darodipine - prescribed 50 mg 2 times a day, steadily reduces systolic and diastolic blood pressure without increasing heart rate.

Amlodipine (norvask) - Available in tablets of 2.5, 5 and 10 mg. The drug has a long-term hypotensive and antianginal effect; it is prescribed once a day initially at a dose of 5 mg; if necessary, after 7-14 days the dose can be increased to 10 mg.

Logimax - a combination drug consisting of the extended-release dihydropyridine drug felodipine and the beta blocker metoprolol. The drug is used once a day.

Thus, calcium antagonists are effective hypotensive and antianginal agents, which lead to the reverse development of left ventricular hypertrophy, improve the quality of life, have a nephroprotective effect, and do not cause significant metabolic disorders and sexual dysfunction.

Indications for the primary use of calcium antagonists in arterial hypertension

combination of hypertension with exertional angina and vasospastic angina;

combination of hypertension and cerebrovascular disease;

combination of arterial hypertension with severe dyslipidemia;

combination of arterial hypertension with chronic obstructive bronchial diseases;

Arterial hypertension in patients with diabetic nephropathy;

The presence of chronic renal failure in patients with arterial hypertension;

Combination of arterial hypertension with heart rhythm disturbances.

Treatment with ACE inhibitors

In addition to the hypotensive effect, ACE inhibitors also have the following positive effects:

reduce left ventricular myocardial hypertrophy;

significantly improve quality of life;

have a cardioprotective effect (reduce the likelihood of developing a recurrent infarction and the risk of sudden death, increase coronary blood flow, eliminate the imbalance between myocardial oxygen needs and its delivery);

Reduce myocardial excitability, tachycardia and the frequency of extrasystole, which is due to an increase in the content of potassium and magnesium in the blood, a decrease in myocardial hypertrophy and hypoxia;

have a beneficial effect on carbohydrate metabolism, increase the uptake of glucose by cells due to the fact that an increase in bradykinin content under the influence of ACE inhibitors increases the permeability of cell membranes to glucose;

exhibit a potassium-sparing effect;

The following ACE inhibitors are most often used to treat arterial hypertension.

Captopril (capoten, tensiomin) - available in tablets of 12.5, 25, 50 and 100 mg, as well as in the form of fixed complex preparations capozide-25(captopril and hydrochlorothiazide 25 MG each) and capozide-50(captopril and hydrochlorothiazide 50 mg).

Treatment of arterial hypertension with capoten begins with a dose of 12.5-25 mg 2-3 times a day, then, in the absence of a hypotensive effect, the dose is gradually increased to 50 mg 2-3 times a day. If necessary, the daily dose of captopril can be increased to 200-300 mg.

Enalapril (enap, renitek, vasotec, xanef) - available in tablets of 2.5, 5, 10 and 20 mg and ampoules for intravenous administration (1.25 mg per 1 ml). The initial dose is 5 mg orally 1 time per day. If necessary, you can gradually increase the dose to 20-40 mg/day in 1-2 doses. Maintenance dose - 10 mg per day. The drug has a renoprotective effect even in cases of significant renal failure.

Cilazapril (inhibase) - prolonged ACE inhibitor. It is superior to captopril and enalapril in strength and duration of action. Usually the drug is prescribed in a dose of 2.5-5 mg 1 time per day, with 2.5 mg in the first 2 days. Next, the dose is selected individually depending on changes in blood pressure.

Ramipril (tritatse) - is a long-acting drug. Treatment begins with taking 2.5 mg of ramipril once a day. If the hypotensive effect is insufficient, the daily dose of the drug can be increased to 20 mg.

Perindopril (prestarium, coversil) - long-acting ACE inhibitor. Perindopril is available in tablets of 2 and 4 mg, prescribed 2-4 mg once a day, in the absence of a hypotensive effect - 8 mg per day.

Quinapril (accupril, accupro) - duration of action - 12-24 hours. For patients with mild and moderate hypertension, the drug is initially prescribed 10 mg 1 time per day, then the daily dose can be increased every 2 weeks to 80 mg (in 2 doses).

ACE inhibitors have the following side effects :

with long-term treatment, inhibition of hematopoiesis is possible (leukopenia, anemia, thrombocytopenia);

cause allergic reactions - itching, redness of the skin, urticaria, photosensitivity;

from the digestive system, sometimes there is a perversion of taste, nausea, vomiting, discomfort in the epigastric region, diarrhea or constipation;

Some patients may experience heavy wheezing breathing, dysphonia, and dry cough;

Contraindications to treatment with ACE inhibitors :

Individual hypersensitivity, including if there is a history of indications of angioedema;

severe aortic stenosis (danger of decreased perfusion of the coronary arteries with the development of myocardial ischemia);

arterial hypotension;

pregnancy (toxicity, development of hypotension in the fetus), lactation (drugs pass into breast milk and cause arterial hypotension in newborns);

renal artery stenosis.

Indications for preferential use of inhibitors ACE for arterial hypertension

ACE inhibitors can be used at any stage of arterial hypertension, both as monotherapy and in combination with calcium antagonists or diuretics (if monotherapy is ineffective), as they significantly improve quality of life, reduce left ventricular myocardial hypertrophy, improve life prognosis, and have a cardioprotective effect .

Indications for the primary use of ACE inhibitors for arterial hypertension:

combination of arterial hypertension with congestive circulatory failure;

combination of arterial hypertension with coronary artery disease, including after myocardial infarction (cardioprotective effect);

arterial hypertension in diabetic nephropathy (nephroprotective effect);

combination of arterial hypertension with chronic obstructive bronchial diseases;

a combination of arterial hypertension with impaired glucose tolerance or diabetes mellitus (ACE inhibitors improve carbohydrate metabolism);

development of unfavorable changes in lipid metabolism and increased levels of uric acid in the blood during the treatment of arterial hypertension with diuretics and beta-blockers;

severe hyperlipidemia in patients with arterial hypertension;

combination of arterial hypertension with obliterating diseases of peripheral arteries.

Angiotensin receptor antagonistsII

A drug losartan (kozaar) is a non-peptide antagonist of AT II receptors and blocks the following effects of AT II related to the pathogenesis of arterial hypertension:

increased blood pressure;

aldosterone release;

renin release (negative feedback);

release of vasopressin;

increased thirst;

release of catecholamines;

development of left ventricular myocardial hypertrophy.

The advantages of losartan are its good tolerability and the absence of side effects characteristic of ACE inhibitors. Indications for use of the drug are the same as for ACE inhibitors. Available in capsules of 50 and 100 mg, used in a dose of 50-100 mg once a day.

Direct vasodilators

Direct vasodilators cause immediate relaxation of blood vessels, primarily arterial ones.

Hydralazine (apressin) - Available in tablets of 10, 25, 50 and 100 mg, as well as in ampoules of 20 mg/ml for intravenous and intramuscular administration. The drug is a peripheral vasodilator, reduces arteriolar resistance, causes a decrease in blood pressure, myocardial load, and increases cardiac output.

The drug is not capable of causing regression of left ventricular myocardial hypertrophy; with prolonged use, tolerance to its hypotensive effect develops.

Hydralazine is initially prescribed at 10 mg 2-4 times a day, then if the hypotensive effect is insufficient, the daily dose is gradually increased to 300 mg in 3-4 doses.

When treated with hydralazine, the following are possible: sideeffects:

Headache; nausea;

tachycardia (due to activation of the sympathetic nervous system); when combined with beta-blockers, tachycardia is less pronounced;

sodium and water retention;

Adelfan-esidrex - a combination drug consisting of adelfan 10 mg hydrochlorothiazide, prescribed 1-4 tablets per day.

α-blockers

Adrenergic blockers block adrenergic receptors at the level of peripheral arterioles, which reduces peripheral resistance and causes a hypotensive effect.

For the treatment of arterial hypertension, highly selective postsynaptic adrenergic blockers are used - prazosin and second generation drugs - doxazosin, terazosin, ebrantil (urapidil).

Postsynaptic adrenergic blockers do not cause reversal of left ventricular myocardial hypertrophy and have an antiatherogenic effect (they reduce the blood levels of cholesterol, triglycerides, atherogenic lipoproteins and increase the level of high-density lipoproteins). They do not cause reflex tachycardia. These drugs almost do not retain sodium and water in the body, do not increase the level of uric acid in the blood, and do not have a negative effect on carbohydrate metabolism.

Prazosin . Treatment with prazosin begins with a dose of 0.5-1 mg at bedtime, after stopping diuretics several days before. After the first dose of the drug, the patient must be in a horizontal position due to the risk of developing orthostatic hypotension (“first dose effect”). In the future, prazosin is prescribed 1 mg 2-3 times a day. The maximum daily dose of the drug is 20 mg.

Prazosin may cause the following: side effects :

sodium and water retention during long-term treatment;

sweating;

dry mouth;

dizziness;

orthostatic hypotension up to fainting when taking the first dose;

Second-generation postsynaptic adrenergic blockers have a prolonged effect, are better tolerated, the phenomenon of the first dose (orthostatic syncope) is less typical for them, and they have more pronounced positive properties such as an antiatherogenic effect and improved glucose metabolism.

Terazosin (hitrin)- The initial dose is 1 mg per day. Subsequently, if there is no effect, you can increase the dose to 5-20 mg 1 time per day.

Doxazosin (kardura) - used in a daily dose of 1 to 16 mg (in 1 dose).

Ebranil(urapidil) - Treatment begins with a dose of 30 mg 2 times a day. In the future, you can gradually increase the daily dose to 180 mg in 2 doses.

α2-Central acting agonists

Centrally acting a2-agonists stimulate adrenergic receptors in the vasomotor center of the medulla oblongata, which leads to inhibition of sympathetic impulses from the brain and a decrease in blood pressure. Centrally acting adrenergic receptor stimulants reverse the development of left ventricular hypertrophy.

Clonidine (clonidine) - for oral treatment of arterial hypertension with clonidine, the initial dose is 0.075-0.1 mg 2 times a day, then every 2-4 days the daily dose is increased by 0.075-1 mg and adjusted to 0.3-0.45 mg (in 2-3 doses). After achieving the hypotensive effect, the dose can be gradually reduced to maintenance, which is usually 0.15-0.2 mg per day.

When using clonidine, it is possible side effects :

severe dry mouth due to inhibition of the secretion of the salivary glands;

drowsiness, lethargy, sometimes depression;

sodium and water retention due to increased reabsorption in the kidneys;

constipation with prolonged use;

impaired carbohydrate tolerance, development of morning hyperglycemia with long-term treatment with clonidine;

a significant increase in blood pressure (up to a hypertensive crisis) with abrupt withdrawal of clonidine;

inhibition of gastric juice secretion;

a sharp drop in blood pressure, loss of consciousness and subsequent amnesia;

glomerular filtration may be reduced.

Contraindications to treatment with clonidine:

treatment with antidepressants (an antagonistic relationship is possible, which interferes with the hypotensive effect of clonidine);

professions that require quick physical and mental reactions;

inhibited state of patients.

Methyldopa (dopegyt, aldomet) -At the beginning of treatment, the dose is 0.25 g 2-3 times a day. Subsequently, the daily dose can be increased to 1 g (in 2-3 doses), the maximum daily dose is 2 g. Methyldopa does not impair renal blood flow or reduce the glomerular filtration rate.

Side effects methyldopa:

Sodium and water retention with long-term use of the drug, an increase in circulating blood volume, a decrease in the hypotensive effect; Taking this into account, it is advisable to combine methyldopa with saluretics;

Lethargy, drowsiness, but to a lesser extent than during treatment with clonidine;

Significant doses of methiddopa can cause depression, night terrors, and nightmares;

possible development of parkinsonism;

menstrual irregularities;

increased secretion of prolactin, the appearance of galactorrhea;

intestinal dyskinesia;

If treatment with methyldopa is abruptly stopped, withdrawal syndrome may develop with a sharp increase in blood pressure.

Contraindications to treatment with methiddopa:

hepatitis and cirrhosis of the liver;

tendency to depression;

parkinsonism;

suspicion of pheochromocytoma;

significant circulatory impairment;

pregnancy.

Sympatholytics

Reserpine - has a direct blocking effect on the sympathetic nervous system, reducing the content of norepinephrine in the central nervous system and peripheral nerve endings.

Reserpine is available in tablets of 0.1 and 0.25 mg, as well as in the form of 0.1% and 0.25% solutions for parenteral administration in ampoules of 1 ml (1 and 2.5 mg, respectively).

The drug is prescribed orally, starting with a daily dose of 0.1-0.25 mg, after meals, then, after 5-7 days, the daily dose is gradually increased to 0.3-0.5 mg.

Side effects reserpine:

nasal congestion and difficulty in nasal breathing due to swelling of the mucous membrane;

drowsiness, depression;

development of parkinsonism with long-term use;

dry mouth;

frequent, loose stools;

weakened libido in men;

bronchospasm;

bradycardia;

increased production of prolactin by the adenohypophysis, persistent galactorrhea;

sodium and water retention;

increased gastric secretion, development of a hyperacid state (heartburn, abdominal pain, exacerbation of gastric and duodenal ulcers).

Contraindications to treatment with reserpine:

Currently, sympatholytics are not considered as first-line drugs for the treatment of arterial hypertension and are used as more accessible (cheap) drugs and, moreover, in the absence of effect from other drugs, as well as due to tradition.

The effect of antihypertensive drugs on myocardial hypertrophy left ventricle

Left ventricular myocardial hypertrophy in hypertension is a risk factor for fatal cardiac arrhythmias, heart failure, and sudden death. In this regard, the effect of some antihypertensive drugs on the reverse development of myocardial hypertrophy is extremely important.

The following antihypertensive drugs can cause regression of myocardial hypertrophy:

beta-blockers: propranolol, acebutalol, nadolol, celi-prolol, devalol, betaxolol, bisoprolol and possibly some others (there are conflicting data regarding atenolol and metoprolol);

calcium antagonists: nifedipine, verapamil, nitrendipine, amlodipine, isradipine; nisoldipine not only does not affect hypertrophy, but can also cause a deterioration in the functional ability of the heart with a sudden increase in blood pressure;

ACE inhibitors;

centrally acting antiadrenergic drugs moxonidine and methyldopa;

The main new provisions of the drug strategy treatment of arterial hypertension

individualized, differentiated therapy of patients, taking into account the clinical and pathogenetic features of arterial hypertension;

refusal of rigid treatment regimens, including mandatory step-down therapy; the possibility of monotherapy not only in patients with “mild”, mild forms of arterial hypertension, but also in patients who require more intensive treatment;

Increasing the role of ACE inhibitors and calcium antagonists in the treatment of arterial hypertension and changing the “hierarchy” of antihypertensive drugs: if previously treatment began with a diuretic or beta-blocker and only in the later stages of hypertension they resorted to α1-blockers, calcium antagonists, ACE inhibitors, then in Currently, these drugs can be “starter”, i.e. treatment can begin with them;

displacement of clonidine, reserpine, ismelin (isobarine) from the list of widely used drugs;

the use of diuretics only in a potassium-sparing regimen and in the second (auxiliary) line in most patients;

clarifying the indications for the use of beta-blockers and increasing the role of selective beta-blockers, as well as beta-blockers with vasodilating properties, in antihypertensive therapy;

mandatory assessment of the possible negative effects of antihypertensive drugs on risk factors for coronary artery disease (atherogenic dyslipoproteinemia), glucose tolerance, and uric acid levels in the blood;

mandatory assessment of the effect of an antihypertensive drug on the reverse development of left ventricular myocardial hypertrophy and quality of life;

development and testing of new promising antihypertensive drugs, in particular true angiotensin II receptor blockers (losartan);

transition during maintenance, indefinitely long-term therapy to long-acting drugs (the “one day - one tablet” principle;

Improved cerebral blood flow (treatment with cerebroangiocorrectors)

Cerebral hemodynamics in hypertension is disturbed ambiguously. Rheoencephalography can be used to identify these disorders.

With a “spastic” type of cerebral hemodynamic disorder It is advisable to include antispasmodics in antihypertensive therapy: papaverine, no-shpa. Calcium antagonists can be recommended as antihypertensive drugs.

In case of venous outflow disturbance from the brain, drugs are recommended that increase the tone of the cerebral veins: small doses of caffeine (0.02-0.03 g per dose for intense headaches), magnesium sulfate, diuretics, beta-blockers.

For mixed types of cerebral hemodynamic disorders Cavinton, cinnarizine are indicated, and among antihypertensive drugs - clonidine (hemiton, clonidine), rauwolfia preparations.

Treatment of hypertensive crisis

Hypertensive crisis- a clinical syndrome characterized by a sudden and violent exacerbation of hypertension or symptomatic arterial hypertension, a sharp increase in blood pressure to individually high levels, subjective and objective manifestations of cerebral, cardiovascular and general autonomic disorders.

Non-emergency (within a few hours) relief of hypertensive crisis

Non-emergency relief of a hypertensive crisis (within 12-24 hours) is carried out when the course is not complicated and not threatening. To relieve such variants of a hypertensive crisis, antihypertensive drugs are used in oral forms.

In addition to the drugs described below, for non-emergency relief of a hypertensive crisis, you can use dibazole in in the form of intramuscular injections (1-2 ml of 1% solution) 3-4 times a day. It is also advisable to include tranquilizers in complex therapy (seduxene etc.), sedatives (valerian,motherwort and etc.).

What
medications should be prescribed when selecting antihypertensive therapy in
first of all? Science is still developing different methods and approaches,
new groups of drugs are being tested. Different doctors may have their own scheme
treatment. However, there are general concepts based on statistics and research.

At the initial stage

In uncomplicated cases, drug antihypertensive therapy
often begin with the use of proven “conventional” drugs: beta-blockers and
diuretics. In large-scale studies involving 48,000 patients,
it has been shown that the use of diuretics and beta-blockers reduces the risks of
cerebrovascular accident, sudden death, myocardial infarction.

Alternative
option is the use of captopril. According to new data, the incidence of
heart attacks, strokes, deaths from conventional treatment, or
when using captopril, it is almost the same. Moreover, a special group
patients who have not previously been treated with antihypertensive drugs, captopril
shows an obvious advantage over conventional therapy, significantly reducing the relative
risk of cardiovascular events by 46%.

Long-term use of fosinopril in patients with diabetes, as well as arterial
hypertension is also associated with a significant reduction in the risk of death, myocardial infarction, stroke,
exacerbation of angina pectoris.

Therapy for left hypertrophy
ventricle

IN
As antihypertensive therapy, many doctors practice the use
angiotensin-converting enzyme (ACE) inhibitors. These drugs have
cardioprotective properties and lead to a decrease in the mass of the LV myocardium (left ventricle). At
study of the degree of impact of various drugs on the LV myocardium
It was revealed that the reverse degree of development of its hypertrophy is most pronounced
specifically with ACE inhibitors, since antiotensin-2 controls growth and hypertrophy
cardiomyocytes and their division. In addition to their cardioprotective effects, ACE inhibitors
have a nephroprotective effect. This is important, because despite all the successes
antihypertensive therapy, the number of patients who develop terminal
renal failure is increasing (compared to the “eighties” in
4 times).

Calcium antagonist therapy

Increasingly used
Calcium antagonists are used as first-line drugs. For example, when
for isolated systemic arterial hypertension (AH), dihydropyridine drugs are effective
long-term blockers
actions of calcium channels. A four-year study of 5,000 patients showed significant effects
nitrendipine on the incidence of cerebral stroke. In another study, basic
The drug was a long-acting calcium antagonist – felodipine. 19,000
patients were followed up for four years. As blood pressure decreases
(blood pressure) beneficial effects increased,
significant reduction in the risk of developing cardiovascular complications and not
the incidence of sudden death increased. "SystEur" study, in
which involved 10 Russian centers, also showed a reduction in the incidence of strokes by 42%
when using nisoldipine.

Antagonists
calcium are also effective against pulmonary arterial hypertension (this is a systemic
hypertension occurring in patients with obstructive pulmonary diseases).
Pulmonogenic hypertension develops several years after the onset of pulmonary
diseases, and there is a clear connection between exacerbation of the pulmonary process and
pressure rises. Advantages of calcium antagonists in pulmonary hypertension
is that they reduce calcium ion-mediated hypoxic
vasoconstriction. Oxygen delivery to tissues increases, decreases
hypoxia of the kidneys, vasomotor center, decreased blood pressure, and also
afterload and myocardial oxygen demand. In addition, the antagonists
calcium reduces the synthesis of histamine, kinin, serotonin in tissues, swelling of the mucous membrane
bronchi and bronchial obstruction. An additional benefit of calcium antagonists (especially
isradipine) – their ability to change metabolic processes in patients with hypertension.
By normalizing or reducing blood pressure, these drugs can prevent the development
dyslipidemia, glucose and insulin tolerance.

U
calcium antagonists, a clear relationship has been identified between the dose and plasma concentration
blood and pharmacological hypotensive effect. By increasing the dose of the drug,
you can, as it were, control the hypotensive effect by increasing or decreasing it. For
long-term treatment of hypertension, long-acting drugs with low
absorption rate (amlodipine, prolonged gastrointestinal form
nifedipine, or osmoadolate, a prolonged form of felodipine). At
using these agents, smooth vasodilation occurs without reflex
activation of the sympathetic-adrenal system, release of catecholamines, reflex tachycardia
and increased myocardial oxygen demand.

Not recommended as first choice based on tolerability
vasodilators of myotropic type of action, central alpha-2-adrenergic
agonists, peripheral adrenergic agonists.

Hypotension (hypotension) is a significant decrease in blood (or arterial) pressure.

This condition rarely leads to the development of any serious illness, but it may cause a person to experience discomfort.

What are the causes of hypotension, and how to deal with it?

Symptoms

Many people have experienced low blood pressure. This condition has a name - hypotension, with A/D values reduced by more than 20% of normal (120/70).

It can be both acute and chronic. Hypotension often indicates the presence of a medical condition.

The following symptoms are observed with low blood pressure:

Causes

Hypotension can be acute, chronic, primary and secondary.

Acute form

The causes of acute hypotension are: poisoning, anaphylactic shock, sudden blood loss, disruption of the heart muscle. This phenomenon develops in just a few minutes or hours, and blood flow in the body is disrupted.

Chronic form

Chronic hypotension does not develop overnight, so all organ systems have already adapted to constant low blood pressure.

Typically, this form of hypotension is observed in people who live in unfavorable climatic conditions (tropics or north).

In some cases, chronic hypotension is considered normal. Low blood pressure is often observed in athletes, since under heavy loads the body is rebuilt: the heart contracts less frequently, which leads to hypotension.

Primary hypotension is an independent disease (in almost all cases, neurocirculatory dystonia).

The reasons for the development of this disease include: severe stress, lack of sleep, constant fatigue, psychological shock and trauma.

Secondary

Secondary hypotension is a symptom of another disease. Here is a list of diseases that are accompanied by low blood pressure:

Diagnostics

Blood pressure is measured with a special device called a tonometer. Blood pressure is measured three times every 5 minutes. It is recommended to monitor your blood pressure throughout the day, and measure it every 3-4 hours.

It is very important to determine the type of hypotension, since the secondary form is a symptom of another disease. To exclude it, an examination is carried out, which includes the following measures: blood test (biochemical), echocardiography, ECG, etc.

Treatment options

A healthy lifestyle and regular rest are the basis for treating hypotension. This disease can be dealt with in several ways: taking medications, using folk remedies (herbs, decoctions, etc.), physiotherapy.

Medication

Hypotension is rarely treated with medication. This method is used when hypotension significantly worsens the quality of life. To treat hypotension, drugs containing caffeine are used.

These include:

Citrapar (for 5-7 days, one tablet every 4 hours);
Citramon (you are allowed to drink no more than 3 tablets per day);
Algon (for 5-7 days, one tablet every 4 hours);
Pentalgin-N (for 5 days no more than 4 tablets per day);
Perdolan (for 5 days, no more than 3 tablets per day).

For treatment, you can also use herbal preparations that have a tonic effect: lemongrass, tincture of ginseng (echinacea, eleutherococcus, etc.). Such tinctures are taken 30 minutes before meals in a dosage of 30 drops per glass of water.

Physiotherapy

Physical therapy is an excellent way to treat hypotension in both adults and children. Properly selected procedures will increase blood pressure to normal levels and improve general condition.

Here is a list of the most commonly used physical therapy techniques:

Home treatment and herbal medicine

Treatment at home involves following a diet, walking in the fresh air, swimming, and active recreation. For hypotension, it is useful to drink strong coffee and tea, as well as eat salty foods.

The diet of people who suffer from hypotension includes foods that increase blood pressure: liver, fresh vegetables and fruits, milk, eggs, nuts, some spices (horseradish, cloves, black or red pepper).

Herbal medicine, or the use of herbal remedies, can help increase blood pressure. For hypotension, you should drink infusions from combinations of the following medicinal plants:

chamomile, lemon balm, wormwood, rosehip, angelica, tartar;
wormwood, lemongrass, rosehip, tartar, chamomile, lemon balm, angelica;
viburnum, lemongrass, valerian, wormwood, immortelle, aralia.

Prevention

Prevention of hypotension is simple. Lead a healthy lifestyle, eat high-quality and healthy foods, drink a lot of water, walk outside more. Don't neglect active games and sports.

Pay special attention to your sleep: every person needs enough rest and sleep. Avoid stress, as it often leads to a decrease in blood pressure.

Hypotension, unlike hypertension, usually does not lead to serious consequences. Scientists have found that low blood pressure sometimes even extends life by several years.

Chronic hypotension helps slow the development of atherosclerosis, since the vessels do not become clogged and remain clean.

Hypotension rarely manifests itself, and its symptoms hardly worsen your health.

What is hypotension? is a phenomenon that is rarely life threatening. Here's what you need to know about this phenomenon:

if you have low blood pressure, be sure to find out whether it indicates the development of any disease;
Lead a healthy lifestyle and eat well, and then the chance of developing hypotension will noticeably decrease;
if you suffer from hypotension, start your day with a cup of strong coffee or tea;
try to avoid various stresses;
get enough sleep and do exercises in the morning.

The concept of antihypertensive therapy includes a set of pharmacological and non-pharmacological measures aimed at stabilizing blood pressure values and preventing complications of hypertension. This is a combined regimen that includes medications and recommendations for modifying risk factors, individually selected for the patient. Their implementation ensures stabilization of pressure indicators, reduction of the actual frequency of complications or their maximum delay, and improvement of the patient’s quality of life.

Introduction

Paradoxical! If everything is fine in words and in printed press materials, then statistics reveal many problems. These include refusal to follow medical recommendations, lack of patient discipline, indulgences, and failure to fully follow prescriptions. This is partly due to the unreasonably low level of trust in medical workers and the abundance of media misinformation about cardiovascular diseases, medicine and beauty. This publication is intended to partially correct this situation, clarify the concept of antihypertensive therapy for the patient, characterize pharmacological treatment and approaches to its improvement in different categories of patients.

This voluminous material provides complete information on the treatment of hypertension with pharmacological and non-pharmacological agents. Combination therapy with antihypertensive drugs is most fully reviewed in the context of the initially set treatment goals. We advise you to carefully and thoughtfully study the article from beginning to end and use it as material explaining the need for treatment of hypertension and methods of therapy.

Any information below is not new to a therapist or cardiologist, but will be very useful to the patient. It will be impossible to draw the right conclusions with a quick glance or a “vertical” reading of the material. It is unacceptable to take any abstracts from this publication out of context and present them as advice to other patients.

Prescribing medications or selecting antihypertensive therapy is a complex job, the success of which depends on competent professional interpretation of risk factors. This is individual work by a specialist with each patient, the result of which should be a treatment regimen that avoids high blood pressure values. It is important that there are no simple, understandable for each patient and universal recommendations for the selection of antihypertensive treatment.

Goals of antihypertensive therapy

One of the many mistakes patients make is the lack of a complete understanding of why antihypertensive therapy is being selected. Patients refuse to think about why they need to treat hypertension and stabilize blood pressure. And as a result, only a few adequately understand why all this is needed and what awaits them if they refuse therapy. So, the first goal to achieve antihypertensive therapy is to improve the quality of life. It is achieved through:

reducing the number of episodes of malaise, headaches, dizziness;
reducing the number of hypertensive crises with the need for emergency care with the involvement of medical workers;
reducing periods of temporary disability;
increasing tolerance to physical activity;
eliminating the painful psychological sensation from the presence of symptoms of hypertension, increasing comfort through stabilization of the condition;
elimination or maximum reduction of episodes of complicated crises of hypertension (nosebleeds, cerebral and myocardial infarction).

The second goal of drug antihypertensive therapy is to increase life expectancy. Although it should be more correctly formulated as the restoration of the previous life expectancy potential that occurred before the development of the disease due to:

reducing the rate of hypertrophic and dilated transformation of the myocardium;
reducing the likelihood and actual incidence of atrial fibrillation;
reducing the likelihood and frequency, reducing the severity or completely preventing the development of chronic kidney disease;
preventing or delaying serious complications of hypertension (myocardial infarction, cerebral infarction, intracerebral hemorrhage);
reducing the rate of development of congestive heart failure.

The third goal of treatment is pursued in pregnant women and is associated with a reduction in the total number of complications and abnormalities during gestation during childbirth or during the recovery period. High-quality and sufficient antihypertensive therapy during pregnancy according to average blood pressure figures is a vital necessity for the normal development of the fetus and its birth.

Treatment approaches

Antihypertensive therapy should be carried out systemically and in a balanced manner. This means that treatment requires adequate consideration of the existing risk factors in a particular patient and the likelihood of developing complications associated with them. The ability to simultaneously influence the mechanism of development of hypertension, prevent or reduce the frequency of possible complications, reduce the likelihood of worsening the course of hypertension and improve the health of the patient forms the basis of modern therapeutic regimens. And in this context, we can consider such a concept as combination antihypertensive therapy. It includes both pharmacological and non-pharmacological areas.

Pharmacological treatment of hypertension is the use of drugs that affect specific biochemical and physical mechanisms of blood pressure formation. Non-drug therapy is a set of organizational measures aimed at eliminating any factors (excess weight, smoking, insulin resistance, physical inactivity) that can cause hypertension, aggravate its course or accelerate the development of complications.

Treatment tactics

Depending on the initial pressure figures and the presence of risk factors on a stratification scale, a specific treatment tactic is chosen. It can consist only of non-drug measures if, based on daily monitoring, stage I hypertension without risk factors is determined. At this stage of the development of the disease, the main thing for the patient is systematic control of blood pressure.

Unfortunately, in this publication it is impossible to briefly, accessiblely and clearly explain to each patient the principles of antihypertensive therapy based on arterial hypertension risk stratification scales. In addition, their assessment is needed to determine the timing of initiation of drug treatment. This is a task for a specially trained and trained employee, while the patient will only need to follow the doctor’s recommendations in a disciplined manner.

Transition to drug treatment

In case of inadequate reduction in blood pressure as a result of weight loss, smoking cessation and dietary modification, antihypertensive drugs are prescribed. Their list will be discussed below, but it is worth understanding that drug therapy will never be sufficient if the treatment regimen is inadequately followed and medications are skipped. Also, drug therapy is always prescribed together with non-drug treatment methods.

It is noteworthy that the basis of antihypertensive therapy in elderly patients is always drugs. This is explained by already existing risk factors for coronary heart disease with an inevitable outcome in heart failure. Drugs used for hypertension significantly slow down the rate of development of cardiac failure, which justifies this approach even from the moment of initial detection of hypertension in a patient over 50 years of age.

Priorities in the treatment of hypertension

The effectiveness of non-drug drugs that prevent the development of complications and help control blood pressure at target levels is very high. Their contribution to reducing the average pressure value with adequate disciplined compliance with recommendations by the patient is 20-40%. However, for hypertension of the 2nd and 3rd degrees, pharmacological treatment is more effective, since it allows you to reduce blood pressure numbers, as they say, here and now.

For this reason, with stage 1 hypertension without complications, the patient can be treated without taking medications. In cases of 2nd and 3rd degrees of hypertension, antihypertensive drugs used in therapy are simply necessary to maintain performance and comfortable life. In this case, priority is given to prescribing 2, 3 or more antihypertensive drugs from different pharmacological groups in low doses instead of using one type of drug in high doses. Several drugs used in the same treatment regimen act on the same or more mechanisms for increasing blood pressure. Because of this, drugs potentiate (mutually enhance) the effect of each other, which provides a stronger effect at low doses.

In the case of monotherapy, one drug, even in high doses, affects only one mechanism of blood pressure formation. Therefore, its effectiveness will always be lower, and the cost will be higher (medicines in medium and high doses always cost 50-80% more). In addition, due to the use of one drug in high doses, the body quickly adapts to the xenobiotic and accelerates its administration.

With monotherapy, the rate of so-called addiction of the body to the drug and the “escape” of the effect of therapy is always faster than in the case of prescribing drugs of different classes. Therefore, it often requires correction of antihypertensive therapy with a change in medications. This creates the preconditions for patients to develop a large list of medications that no longer “work” in their case. While they are effective, they just need to be combined correctly.

Hypertensive crisis

A hypertensive crisis is an episode of increased blood pressure to high levels during treatment with the appearance of stereotypical symptoms. Among the symptoms, the most common are a pressing headache, discomfort in the parietal and occipital region, flashing spots before the eyes, and sometimes dizziness. Less commonly, a hypertensive crisis develops with complications and requires hospitalization.

It is important that even against the background of effective therapy, when average blood pressure numbers meet the norms, a crisis can (and periodically does) occur. It appears in two versions: neurohumoral and water-salt. The first develops quickly, within 1-3 hours after stress or heavy exercise, and the second develops gradually, over 1-3 days with excessive accumulation of fluid in the body.

The crisis is treated with specific antihypertensive drugs. For example, in the case of a neurohumoral crisis, it is reasonable to take the drug Captopril and Propranolol or seek medical help. In case of water-salt crisis, the most correct option would be to take loop diuretics (“Furosemide” or “Torasemide”) together with “Captopril”.

It is important that antihypertensive therapy during a hypertensive crisis depends on the presence of complications. The uncomplicated variant can be treated independently according to the above scheme, while the complicated one requires calling an ambulance or a visit to the emergency department of inpatient healthcare institutions. Crises more than once a week indicate the failure of the current antihypertensive regimen, which requires correction after consulting a doctor.

Rare crises that occur less than once every 1-2 months do not require correction of the main treatment. Intervention in an effective regimen of combination antihypertensive therapy in elderly patients is carried out as a last resort, only when evidence of “escape” of the effect is obtained, in case of poor tolerability or allergies.

Groups of drugs for the treatment of hypertension

There are a huge number of trade names among antihypertensive drugs, which are neither necessary nor possible to list. In the context of this publication, it is appropriate to highlight the main classes of drugs and briefly characterize them.

Group 1 - inhibitors The ACE inhibitor group is represented by such drugs as Enalapril, Captopril, Lisinopril, Perindopril, Ramipril, Quinapril. These are the main drugs for the treatment of hypertension, which have the ability to slow down the development of myocardial fibrosis and delay the onset of heart failure, atrial fibrillation, and renal failure.

Group 2 - angiotensin receptor blockers. The drugs of this group are similar in effectiveness to ACE inhibitors, since they exploit the same angiotensinogen mechanism. However, ARBs are not enzyme blockers, but rather inactivators of the angiotensin receptor. They are somewhat inferior in effectiveness to ACE inhibitors, but also slow down the development of CHF and chronic renal failure. This group includes the following drugs: Losartan, Valsartan, Candesartan, Telmisartan.

Group 3 - diuretics (loop and thiazide). "Hypothiazide", "Indapophone" and "Chlorthalidone" are relatively weak thiazide diuretics, convenient for continuous use. Loop diuretics "Furosemide" and "Torasemide" are well suited for stopping crises, although they can also be prescribed on an ongoing basis, especially in cases of already developed congestive CHF. Among diuretics, their ability to increase the effectiveness of ARBs and ACEIs is of particular value. Antihypertensive therapy during pregnancy involves the use of diuretics as a last resort, when other drugs are ineffective, due to their ability to reduce placental blood flow, while in other patients this is the main (and almost always mandatory) drug for the treatment of hypertension.

Group 4 - adrenergic blockers: Metoprolol, Bisoprolol, Carvedilol, Propranolol. The latter drug is suitable for relieving crises due to its relatively rapid action and effect on alpha receptors. The remaining drugs on this list help control blood pressure, but are not the main ones in the antihypertensive regimen. Doctors value their proven ability to increase the life expectancy of patients with heart failure when taken simultaneously with ACE inhibitors and diuretics.

Group 5 - calcium channel blockers: Amlodipine, Lercanidipine, Nifedipine, Diltiazem. This group of drugs is widely used in the treatment of hypertension because it can be taken by pregnant patients. Amlodipine has a beneficial effect of nephroprotection, which, together with the use of ACE inhibitors (or ARBs) and diuretics, slows the development of chronic renal failure in malignant hypertension in non-pregnant patients.

Group 6 - other medicines. Here it is necessary to indicate heterogeneous drugs that have found use as antihypertensives and have heterogeneous mechanisms of action. These are Moxonidine, Clonidine, Urapidil, Methyldopa and others. A complete list of medications is always present to the doctor and does not require memorization. It is much more beneficial if each patient remembers well his antihypertensive regimen and those drugs that were successfully or unsuccessfully used previously.

Antihypertensive therapy during pregnancy

During pregnancy, the most commonly prescribed drugs are Methyldopa (category B), Amlodipine (category C), Nifedipine (category C), Pindolol (category B), Diltiazem (category C). At the same time, independent choice of drugs by a pregnant woman is unacceptable due to the need for primary diagnosis of increased blood pressure. Diagnostics is required to exclude preeclampsia and eclampsia - dangerous pathologies of pregnancy. The selection of treatment will be carried out by the attending physician, and any previously not observed (before pregnancy) increase in blood pressure in a pregnant woman should be carefully studied.

Antihypertensive therapy during lactation is subject to strict rules: in the first case, if blood pressure numbers are not higher than 150/95, breastfeeding can be continued without taking antihypertensive drugs. In the second case, with blood pressure in the range of 150/95-179/109, low-dose use of antihypertensive drugs is practiced (the dose is prescribed by a doctor and monitored under the supervision of medical staff) with continued breastfeeding.

The third type of antihypertensive therapy in pregnant and lactating women is the treatment of hypertension, including combined treatment, with the achievement of target blood pressure values. This requires avoidance of breastfeeding and continued use of essential medications: ACE inhibitors or ARBs with diuretics, calcium channel blockers and beta blockers, if required for successful treatment.

Antihypertensive therapy for chronic renal failure

Treatment of hypertension in chronic renal failure requires clinical medical supervision and careful attention to doses. The priority groups of drugs are ARBs with loop diuretics, calcium channel blockers and beta blockers. Combination therapy of 4-6 drugs in high doses is often prescribed. Due to frequent crises with chronic renal failure, the patient may be prescribed Clonidine or Moxonidine for continuous use. It is recommended to stop hypertensive crises in patients with chronic renal failure using injectable Clonidine or Urapidil with the loop diuretic Furosemide.

Arterial hypertension and glaucoma

In patients with diabetes mellitus and chronic renal failure, damage to the organ of vision often occurs, associated with both retinal microangiopathy and hypertensive damage. An increase in IOP to 28 with or without antihypertensive therapy indicates a tendency to develop glaucoma. This disease is not associated with arterial hypertension and retinal damage, but is damage to the optic nerve as a result of increased intraocular pressure.

A value of 28 mmHg is considered borderline and characterizes only the tendency to develop glaucoma. Values above 30-33 mmHg are a clear sign of glaucoma, which, together with diabetes, chronic renal failure and hypertension, can accelerate vision loss in the patient. It should be treated together with the main pathologies of the cardiovascular and urinary systems.