Active application of non-pharmacological and/or pharmacological therapies to treat hypertension and control it within the normal range can effectively prevent the occurrence of related complications; if target organ damage has already occurred, it can help delay or even avoid the deterioration of cardiac, cerebral and renal lesions, improve the quality of life of patients, and reduce the rate of death and disability.
(A) Basic principles of antihypertensive therapy.
The treatment of hypertension should be closely integrated with the aforementioned grading and risk stratification scheme, and the patient’s elevated blood pressure level, coexisting risk factors, clinical conditions, and target organ damage should be comprehensively considered to determine a reasonable treatment plan. According to the spirit of the new guidelines, different treatment principles should be applied to patients with hypertension of different risk levels. The details are as follows.
Low-risk patients: The main focus is to improve lifestyle, and if it is not effective after 6 months, then drug therapy will be given;
Intermediate-risk patients: first actively improve lifestyle, while observing the patient’s blood pressure and other risk factors for several weeks to further understand the situation, and then decide whether to start drug therapy;
High-risk patients: immediate medication must be given;
Very high risk patients; intensive treatment of hypertension and coexisting risk factors and clinical conditions must be started immediately.
Regardless of the risk level of the hypertensive patient, poor lifestyle should be corrected first or simultaneously; in other words, improving the patient’s lifestyle should be the basis for treating patients with any type of hypertension. Some patients with mild hypertension can be reduced or even exempted from antihypertensive medication after improving their lifestyle; patients with more severe disease can also improve the therapeutic effect of antihypertensive medication and reduce the dose or type of medication after improving their lifestyle. This point has not received sufficient attention in our past clinical practice.
(B) The goals of antihypertensive treatment.
According to the spirit of the new guidelines, blood pressure in young and middle-aged hypertensive patients should be reduced to below 130/85 mmHg. In combination with target organ damage and/or diabetes mellitus, blood pressure should be lowered to below 130/80 mmHg; hypertension combined with renal insufficiency and urinary protein more than 1 g/24 hours should be lowered to at least 130/80 mmHg or even below 125/75 mmHg. In elderly patients with hypertension, blood pressure should be controlled to 140/90 mmHg or less, and special attention should be paid to lowering systolic blood pressure.
For many years it has been thought that antihypertensive treatment of the elderly should be more lenient, a view that has been thoroughly disproved by a wealth of evidence-based medical evidence. Studies have shown that tighter control of blood pressure in the elderly can be beneficial without increasing the incidence of adverse effects.
Evidence from numerous large-scale clinical trials shows that blood pressure is as low as possible within the normal ideal range, and that lowering blood pressure to normal or ideal levels does not worsen cardiac, cerebral, or renal insufficiency or aggravate symptoms. As long as blood pressure is lowered slowly and steadily to below the target level, both the risk of various cardiovascular and cerebrovascular events can be significantly reduced and symptoms can be alleviated.
(C) Non-pharmacological treatment of hypertension
As mentioned earlier, hypertension should be treated with a combination of measures, and any treatment plan should be based on non-pharmacologic therapy. Active and effective non-pharmacological treatment can interfere with the pathogenesis of hypertension through multiple pathways, play a role in lowering blood pressure, and help reduce the incidence of target organ damage. Non-pharmacological treatment includes improving lifestyle and eliminating behaviors and habits that are detrimental to mental and physical health to achieve a reduction in the risk of developing hypertension as well as other cardiovascular diseases, which include.
1. Weight control: Almost all overweight hypertensive patients can benefit from weight reduction by reducing their weight (8). The method of weight loss is on the one hand to reduce the total calorie intake, emphasizing less fat and limiting excessive carbohydrate intake, and on the other hand to increase physical exercise such as running, tai chi, aerobics, etc. In the process of weight loss also need to actively correct other bad habits, such as quit smoking and alcohol, etc.
2, reasonable diet: mainly include limiting sodium intake (according to WHO recommendations do not exceed 6 grams per day), reduce dietary fat, strictly limit alcohol consumption, eat more vegetables and fruits and other foods rich in vitamins and fiber, intake of adequate protein and potassium, calcium, magnesium.
3, moderate exercise: hypertension patients through reasonable physical exercise can make some degree of blood pressure decline, and reduce the occurrence of certain complications. The exercise program (including the type of exercise, intensity, frequency and duration of exercise) varies from person to person and needs to be based on the level of elevated blood pressure, target organ damage and other clinical conditions, age, and climatic conditions.
According to the reference standards provided in the new guidelines, the common exercise intensity index can be used to reach a maximum heart rate of 180 (or 170) minus the usual heart rate during exercise, or 60-85% of the maximum heart rate as the appropriate heart rate for exercise if precision is required. Exercise frequency generally requires 3-5 times a week, each lasting 20-60 minutes can be.
4, maintain a healthy state of mind: bad emotions can have a more obvious impact on blood pressure, joy, anger, worry, thought, sadness, fear, shock, etc. can raise blood pressure to varying degrees. Life is too fast-paced, too much pressure is also a common cause of blood pressure rise. In addition, a bad state of mind often causes patients to become addicted to alcohol and tobacco, which indirectly affects blood pressure levels. Therefore, patients with hypertension should strive to maintain a relaxed, calm, optimistic and healthy state of mind.
(D) drug treatment of hypertension
1. Principles of drug therapy.
1. Start from the minimum effective dose to reduce the occurrence of adverse reactions. If the antihypertensive effect is effective but the blood pressure control is still not satisfactory, the dosage can be gradually increased to obtain the best efficacy;
2. Once-daily, 24-hour effective long-acting agents are strongly recommended to ensure stable blood pressure lowering for 24 hours a day, which can help prevent target organ damage and prevent sudden death, stroke and heart attack from low blood pressure at night to sudden rise in blood pressure in the early morning. These agents also greatly increase compliance with treatment and facilitate patients’ adherence to regular medication;
3. When a single drug is not effective, it is not advisable to increase the dose of a single drug too much, but to use two or more drugs in combination early, which can help to improve the effect of lowering blood pressure without increasing the adverse effects;
4. When judging whether one or several antihypertensive drugs are effective and whether the treatment plan needs to be changed, the time required for the drug to reach its maximum effect should be fully considered. It is not reasonable to change the treatment plan too often before the drug has its maximum effect.
5. Hypertension is a lifelong disease, and once diagnosed, treatment should be adhered to for life. This is especially true when using antihypertensive drugs.
2, the choice of antihypertensive drugs: there are many types of antihypertensive drugs commonly used in clinical practice. Regardless of the drug chosen, the purpose of treatment is to control blood pressure in the ideal range and prevent or reduce target organ damage. The new guidelines emphasize that the selection of antihypertensive drugs should be based on the individual condition of the treated patient, the action, metabolism, adverse effects and drug interactions of the drugs, and the following points should be taken into consideration to make a decision.
1. the presence of cardiovascular risk factors in the target population;
2. The presence of target organ damage, cardiovascular disease (especially coronary artery disease), renal disease and diabetes mellitus;
3. whether the subject has a combination of other diseases that are affected by antihypertensive drugs;
4. whether there is any possible interaction with the drugs used for the treatment of the combined diseases;
5. Whether there is evidence of reduction in cardiovascular morbidity and mortality and the strength of the drug chosen;
6. the availability and price of antihypertensive drugs in the region and the ability of the patients to pay.
3. Clinically used antihypertensive drugs: There are six major categories of clinically used antihypertensive drugs: diuretics, alpha-blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and angiotensin? II receptor antagonists. The efficacy and adverse effects of antihypertensive drugs vary widely among individuals and should be given due attention in clinical application. The specific choice of one or more drugs should be considered in a comprehensive manner with reference to the aforementioned principles of drug use.
These drugs can reduce the volume of extracellular fluid, lower the volume of cardiac output, and lower blood pressure through the effect of sodium. The antihypertensive effect is weak and slow, but when combined with other antihypertensive drugs, they often have additive or synergistic effects, and are often used as the basic treatment of hypertension. It is mainly used for mild to moderate hypertension.
These drugs can affect the blood electrolyte metabolism, and need to pay attention to monitoring in the process of drug use. In addition, thiazides can also interfere with the metabolism of sugar, lipids, and uric acid, so they should be used with caution in people with diabetes and dyslipidemia, and are prohibited in patients with gout. Potassium-protective diuretics should be avoided in combination with ACE inhibitors because they can increase blood potassium, and are prohibited in patients with renal insufficiency.
2.а-blockers can block post-synaptic а-receptors and counteract the vasoconstrictive effect of norepinephrine. The antihypertensive effect is good, but the clinical application is gradually decreasing in recent years because of the tendency to cause postural hypotension. Since these drugs have no effect on metabolic processes such as blood glucose and lipids, they are still a good choice when patients have relevant clinical conditions.
3. β-blockers exert antihypertensive effects through various mechanisms such as slowing down heart rate, reducing myocardial contractility, decreasing cardiac blood output, and reducing plasma renin activity. Its hypotensive effect is weak, with a long onset of action (1-2 weeks), and is mainly used for mild to moderate hypertension, especially in young and middle-aged patients with a rapid heart rate at rest (>80 beats/min) or in patients with combined angina pectoris or post-myocardial infarction. Contraindicated in patients with heart block, severe bradycardia, asthma, chronic obstructive pulmonary disease and peripheral vascular disease. Use with caution in patients with insulin-dependent diabetes mellitus and hyperlipidemia. See separate chapter for use in combination with heart failure.
Calcium antagonists are used to lower blood pressure mainly by blocking calcium channels in the cell plasma membrane and relaxing the smooth muscle of the peripheral arterial vessels to lower peripheral vascular resistance. It can be used in various degrees of hypertension, especially in the elderly with hypertension or combined with stable angina pectoris. Because of the negative effect on conduction function and myocardial contractility, non-dihydropyridines are prohibited in heart block and heart failure.
The clinical use of fast-acting dihydropyridine calcium antagonists is gradually decreasing due to the suspicion of inducing sudden death, and the use of long-acting preparations is advocated. However, because of its generally low price, the rapid-acting preparations are still an alternative antihypertensive drug in rural and remote areas with poor economic conditions. Unstable angina pectoris and acute myocardial infarction should not be applied quick-acting dihydropyridine calcium antagonists.
Angiotensin-converting enzyme inhibitors reduce the production of angiotensin II by inhibiting ACE, and reduce the degradation of bradykinin by inhibiting kinase to exert antihypertensive effects. It is suitable for all types of hypertension, especially for the following conditions: hypertension with left ventricular hypertrophy, left ventricular insufficiency or heart failure, post-myocardial infarction, diabetic kidney damage, hypertension with peripheral vascular disease, etc.
In addition to its antihypertensive effect, it also exerts beneficial effects on the cardiovascular system through various mechanisms, making it an excellent cardiovascular drug. However, it can cause irritating cough and limit its application to some extent. It is contraindicated in pregnancy and in patients with renal artery stenosis and renal failure (blood creatinine >265μmol/L or 3mg/dL).
6. Angiotensin II receptor blockers exert antihypertensive effects by directly blocking angiotensin II receptors. Clinical effects are the same as those of ACE inhibitors, but they do not cause adverse effects such as cough. It is mainly used for patients who cannot tolerate ACE inhibitors.
4, the combined application of antihypertensive drugs Evidence-based medical evidence shows that the combined application of different types of antihypertensive drugs in small doses is more effective than a single larger dose of a drug and less adverse reactions, so the combined application of antihypertensive drugs is increasingly respected and attention. The combination of different drugs can be synergistic or additive, while their adverse effects can be offset or at least not overlap or additive.
The number of drugs used in combination should not be too many, too many can have complex drug interactions. The ideal combination regimens are.
1. ACE inhibitors (or angiotensin II receptor antagonists) with diuretics;
2. calcium antagonists and beta-blockers;
3. ACE inhibitors and calcium antagonists;
4. Diuretics and β-blockers;
5. α-blockers and β-blockers.
The need for compounded forms of antihypertensive drugs is controversial. The advantage of these dosage forms is that they are easy to take, improve the patient’s compliance with treatment, and their efficacy is generally better; the disadvantage is that the formula content and ratio are fixed, and it is difficult to finely adjust the dose of one or several drugs according to the specific clinical situation. In clinical practice, it should be considered in conjunction with the specific circumstances of the patient.
5, antihypertensive treatment of the elderly A series of large-scale clinical studies unveiled in recent years have shown that active antihypertensive treatment can also benefit elderly patients with hypertension. The goal of blood pressure lowering in the elderly should also be below 140/90mmHg. It is a completely wrong concept that blood pressure in the elderly should not be too low.
However, the selection of antihypertensive drugs should take into account the characteristics of this special population, such as frequent multi-organ diseases, varying degrees of decreased liver and kidney function, relatively poor drug tolerance, and a relatively high incidence of drug-related adverse reactions. In general, diuretics, long-acting dihydropyridines, β-blockers, ACE inhibitors, etc. are better choices.
The principles of antihypertensive treatment for this condition are basically the same as those for general hypertension, but drug selection should take into account whether the drugs used have any effect on the fetus. It is generally believed that ACE inhibitors and angiotensin II receptor antagonists may cause fetal growth retardation, low amniotic fluid, or neonatal renal failure, and may also cause fetal malformation, so they should not be used.