Hypertension is harmful and the most important risk factor for cardiovascular disease, but blood pressure is relatively easy to control, and its examination and follow-up monitoring methods are relatively simple, with good treatment benefits and easy to see results. With more than 300 million hypertensive patients in China, hypertension is used as an important entry point for community-based chronic disease control. Most of the diagnosis and evaluation of hypertension are performed in tertiary hospitals, but community physicians correctly understand the concept and strategy of hypertension, have a good grasp of the characteristics of antihypertensive drugs, and timely detect and correct the adverse effects of antihypertensive drugs, which can help hypertensive patients maintain an effective treatment plan in the long term and improve the success rate of community chronic disease management of hypertension.
I. Mainstream philosophy and strategy of hypertension treatment.
1, “early intervention is better than late treatment”, antihypertensive treatment strategies and key populations shift to the early stage, the front end of the entire cardiovascular event chain will become the main battlefield of antihypertensive treatment.
2, the strategy of hypertension treatment: control the total cardiovascular risk. The survey of Chinese outpatients with hypertension shows that the proportion of patients with combined multiple risk factors is as high as 45.1%; while treating hypertension, patients should be intervened with all risk factors checked out and various clinical conditions that exist at the same time in patients should be dealt with appropriately.
3. The quality of antihypertensive treatment is better than the quantity. Intensive antihypertensive is not equal to optimal antihypertensive, especially in the coronary heart disease and diabetes population, the lower the blood pressure control target is not better. Blood pressure variability, as a new indicator, will occupy an important position in the evaluation of antihypertensive efficacy.
4, the benefits of antihypertensive treatment mainly come from the blood pressure drop itself, and all 5 types of antihypertensive drugs can be used as initiating and maintaining drugs.
5, pay attention to the target value of blood pressure lowering for different groups of people: general hypertension patients blood pressure to 140/90 mmHg or less; elderly systolic hypertension patients systolic blood pressure to 150 mmHg or less; young people or diabetes and renal disease, coronary heart disease, post-stroke patients to 130/80 mmHg or less, but generally not less than 110/70 mmHg.
6, emphasis on continuous correction of poor lifestyle, change in poor lifestyle can directly reduce the risk of cardiovascular events and blood pressure, the best health economics benefits. Weight loss of 10 kg (BMI 18.5-24.9) can reduce blood pressure by 5 – 20 mmHg, adoption of the DASH diet can reduce blood pressure by 8 – 14 mmHg, reduction of sodium intake sodium <2.4 g can reduce blood pressure by 2 - 8 mmHg, physical activity 30 min/d can reduce blood pressure by 4 - 9 mmHg, and control of alcohol intake <25 g/d can reduce blood pressure by 2C4 mmHg blood pressure.
Second, the main characteristics of antihypertensive drugs and clinical monitoring.
Calcium antagonists
Use characteristics: Applicable to all types of hypertensive patients, no clear absolute contraindication; can be combined with other four antihypertensive drugs, and angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor antagonists (ARB) in combination with a synergistic anti-atherosclerotic effect. China hypertension trial evidence (Syst-China, STONE, FEVER, CHIEF), suitable for national conditions, high salt diet, alcoholism, smoking, etc. does not affect its antihypertensive efficacy, no significant effect on glucose metabolism and lipid metabolism.
Monitoring points: reflex sympathetic excitation causes rapid heartbeat, and the combination of B-blockers can counteract its side effects. In case of ankle edema, angiotensin-converting enzyme inhibitors or diuretics can be used to reduce the side effects. Other side effects include facial flushing and gingival hyperplasia.
Diuretics
Characteristics of use: Inexpensive and efficacious. It is suitable for patients with mild to moderate hypertension, elderly, simple systolic hypertension, obesity and hypertension combined with heart failure. In combination, when other antihypertensive monotherapy is ineffective, the addition of diuretics is effective.
Monitoring points: hypokalemia, insulin resistance and disorders of lipid metabolism, gout. Diuretic-associated abnormalities of glucose and lipid metabolism are associated with hypokalemia after drug administration, and the use of angiotensin-aldosterone inhibitors can partially counteract their side effects.
B-blockers
Characteristics of use: Used for mild to moderate hypertension, especially when the resting heart rate is fast (>80 beats/min), and in combination with diuretics or dihydropyridine calcium antagonists to increase the antihypertensive effect and reduce the side effects of reflex heart rate acceleration.
Monitoring points: fatigue feeling, cold limbs. It can cause disorders of glucose metabolism and lipid metabolism. The choice of B1 receptor highly selective long-acting preparation can reduce its interference with glucose and lipid metabolism. Do not use B receptor blockade if heart rate is below 55 beats/min, or if there is atrioventricular block of degree II or higher, or if asthma and peripheral vascular disease are present before drug administration. Direct discontinuation of B-blockers may result in rebound, so a gradual reduction in dosage and then discontinuation must be used in the course of treatment.
Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor antagonists (ARB)
Characteristics of use: Safe and effective antihypertensive drugs for the treatment of all levels of hypertension, especially for hypertension with: left ventricular hypertrophy, heart failure, post-myocardial infarction ventricular remodeling, diabetes mellitus, peripheral vascular disease and Raynaud’s phenomenon. Bilateral renal artery stenosis is contraindicated.
Monitoring points: hypotension, hyperkalemia, creatinine elevation, the incidence of adverse reactions is the same for both types of drugs, hypotension occurs more often when the effective blood volume is low. Cough occurs more often with ACEI than with ARB.