According to the results of the 2008 census and epidemiological survey, the incidence of hypertension in China has continued to rise in recent years, and the level of blood pressure is continuously positively correlated with the incidence of cardiovascular disease, and cardiovascular disease has become the main cause of death and disability in Chinese people, with hypertension being the first risk factor. Therefore, it is very important to actively prevent and treat hypertension to reduce cardiovascular and cerebrovascular complications, reduce late medical costs, reduce the burden on society and improve the quality of life.
1.Non-pharmacological treatment: Non-pharmacological treatment mainly refers to lifestyle interventions, i.e., removing behaviors and habits that are detrimental to physical and psychological health. It can not only prevent or delay the occurrence of hypertension, but also lower blood pressure and improve the efficacy of antihypertensive drugs, thus reducing cardiovascular risk. It is the foundation of pharmacotherapy and an important adjunct to it.
(1) Smoking cessation
Smoking is one of the major risk factors for cardiovascular disease and cancer. Passive smoking also significantly increases the risk of cardiovascular disease. Smoking can cause endothelial damage and significantly increase the risk of atherosclerotic disease in patients with hypertension. The benefits of quitting smoking are very certain and can be beneficial at any age.
(2) Limit alcohol
Although some studies suggest that small amounts of alcohol may reduce the risk of coronary heart disease, long-term heavy alcohol consumption can lead to increased blood pressure, and limiting the amount of alcohol consumed can significantly reduce the risk of developing hypertension. Moreover, alcohol consumption can counteract the efficacy of antihypertensive drugs. Therefore, it is not advocated to prevent coronary heart disease with a small amount of alcohol, not advocate hypertensive patients drink alcohol, if you drink alcohol, it should be in small amounts: less than 50ml, 100ml, 300ml of white wine, wine (or rice wine) and beer, respectively. the new WHO recommendation on alcohol is: wine, the less the better.
(3) Reduce sodium intake
Sodium can significantly increase blood pressure and the risk of hypertension, while potassium salt can counteract the effect of sodium to increase blood pressure. The sodium intake of all residents in China is significantly higher than the current WHO recommendation of less than 6 grams per day, while the potassium intake is severely inadequate. Therefore, all hypertensive patients should take various measures to reduce sodium intake and increase potassium intake in food as much as possible. The main measures include: reducing the amount of salt used in cooking as much as possible, suggesting the use of a rationable salt spoon; reducing the amount of MSG, soy sauce and other condiments containing sodium; reducing or not eating processed foods with high sodium content, such as pickles, ham, sausages and various types of fried foods; and increasing the intake of vegetables and fruits.
(4) Weight control
Overweight and obesity is one of the important causes of elevated blood pressure, and central obesity with abdominal fat accumulation as a typical feature will further increase the risk of cardiovascular and metabolic diseases such as hypertension, appropriate reduction of elevated body weight, reduce body fat content, can significantly reduce blood pressure.
The easiest and most commonly used physiological measures of overweight and obesity are body mass index [calculated as: weight (kg)? Height (m)2] and waist circumference. The normal body mass index for adults is 18.5-23.9 kg/m2, and 24-27.9 kg/m2 is overweight, suggesting the need for weight control; a BMI greater than 28 kg/m2 is obese and should be reduced. Adults with normal waist circumference <90/85 cm (male/female), if the waist circumference is greater than 90/85 cm (male/female), it also suggests the need for weight control, if the waist circumference is greater than 95/90 cm (male/female), more weight should be reduced.
The most effective weight reduction measures are to control energy intake and increase physical activity. In terms of diet, we should follow the principle of balanced diet, control the intake of high-calorie foods (high-fat foods, sugary drinks and alcohol, etc.), and control the amount of staple foods (carbohydrates) appropriately. In terms of exercise, regular, moderate intensity aerobic exercise is an effective way to control weight. The rate of weight loss varies from person to person, usually 0.5~1 kg per week is appropriate. For patients with severe obesity whose weight loss is not satisfactory by non-drug measures, weight control drugs should be used under the guidance of a doctor.
(5) Physical activity
General physical activity can increase energy consumption, very beneficial to health. And regular physical exercise can produce important therapeutic effects, can reduce blood pressure, improve sugar metabolism, etc.. Therefore, it is recommended that appropriate physical activity of about 30 minutes a day; and aerobic physical exercise (sweating) 2-3 times a week, such as walking, jogging, cycling, swimming, doing aerobics, dancing and rowing, etc.
(6) Reduce mental stress and maintain psychological balance
Psychological or mental stress causes psychological stress (reaction), that is, the body’s response to the stimulation of psychological and physiological factors in the environment. Long-term, excessive psychological reactions, especially negative ones, can significantly increase cardiovascular risk. Various measures should be taken to help patients prevent and relieve mental stress and life stress, correct and treat pathological psychology, and advise patients to seek professional psychological counseling or treatment if necessary.
(7) Diet and Chinese medicine
Our traditional culture and medicine attach great importance to the influence of diet on physical fitness. A long-term high-energy diet can cause diseases such as obesity, metabolic syndrome, diabetes and hypertensive atherosclerosis. Therefore, advocate a low-calorie, high-fiber diet with more vegetables, fruits, mixed grains and coarse grains, and less fried, high-sugar and high-protein foods; avoid or eat less spicy foods (such as leeks and chili peppers) in vegetables, and eat more green leafy vegetables, radish, bitter melon, lettuce, celery, water chestnuts and wild rice, which can improve the physique and assist in lowering blood pressure; many health products containing ginseng, royal jelly and deer antler should also be avoided. Proprietary Chinese medicines are recommended to contain cooling drugs such as antelope horn, geranium, pinellia blood circulation, geranxin and other drugs.
2.Medication
The main goal of drug therapy is to achieve the blood pressure standard, with the aim of minimizing the risk of cardiovascular morbidity and mortality. It is required to intervene in all reversible risk factors (smoking, dyslipidemia, diabetes) and coexisting clinical conditions (coronary artery disease, lower extremity atherosclerosis, carotid atherosclerosis, intracranial atherosclerosis and cerebral infarction, renal small artery sclerosis) while treating hypertension.
(1) Timing of starting drug therapy
Therapeutic lifestyle interventions should be taken immediately after the initial diagnosis of hypertension. high-risk very high-risk patients with grade 3 hypertension or with target organ damage or coexisting clinical conditions should start drug therapy immediately. low-dose drug therapy should be considered for patients with grade 1-2 hypertension with dizziness and other uncomfortable symptoms; intermediate-risk patients with grade 1-2 hypertension without symptoms (combined with 1-2 risk factors) should be followed up for 1 month, such as 2 measurements of mean If the average blood pressure is 140/90 mmHg, drug therapy will be started; if the average blood pressure is 140/90 mmHg, drug therapy will be started in low-risk patients after 3 months of follow-up.
(2) Treatment goal
To reduce blood pressure to 140/90 mmHg or less in general hypertension; to 150/90 mmHg or less in elderly hypertension (over 65 years old); to 130/80 mmHg or less in young people or patients with diabetes, cerebrovascular disease, stable coronary artery disease, or chronic kidney disease. Blood pressure should be lowered to the above target blood pressure levels in a timely manner, but not as quickly as possible. In most patients with hypertension, blood pressure should be gradually lowered to the target level over 4-12 weeks, depending on the disease. Younger patients with a shorter duration of hypertension may have a faster rate of blood pressure reduction; however, older patients with a longer duration of disease or those with target organ damage or complications should have a slower rate of blood pressure reduction.
(3) Treatment principles
a. Small dose, start treatment with a smaller dose to minimize adverse effects, and can gradually increase the dose.
b, smooth antihypertensive, try to apply long-acting preparations, in order to effectively control nighttime blood pressure and morning peak blood pressure, more effective prevention of cardiovascular and cerebrovascular complications. If the use of medium- and short-acting preparations, it is necessary to use the drug 2-3 times a day to achieve smooth control of blood pressure.
c. Combination therapy, in order to reduce adverse reactions and increase the efficacy, two or more drugs can be combined when the efficacy of low-dose monotherapy is unsatisfactory. For patients with blood pressure ≥ 160/100mmHg or above medium risk, a small dose of two drugs can be used in combination therapy at the beginning, or with a small dose of fixed compounding.
d. Individualization: according to the patient’s specific situation and tolerance and personal wishes or long-term affordability, choose the appropriate antihypertensive drugs for the patient.
(4) Commonly used antihypertensive drugs: CCB, ACEI, ARB, diuretics and b-blockers and their low-dose fixed-combination preparations can be used as initial or long-term maintenance drugs for antihypertensive therapy, monotherapy or combination therapy. Although the Chinese guidelines for the prevention and treatment of hypertension and the American and European guidelines recommend that all five major classes of antihypertensive drugs can be used as first-line agents, treatment plans should still be individualized, and the rational use of drugs should be based on the patient’s risk factors, subclinical target organ damage and combined clinical conditions, with priority given to a particular class of antihypertensive drugs, and sometimes these clinical conditions can be referred to as strong indications.
a. Calcium channel blockers CCB: including dihydropyridine calcium antagonists and non-dihydropyridine calcium antagonists. The former, such as nifedipine, nifedipine, lacidipine, amlodipine, and felodipine. There are no absolute contraindications to CCB, but some patients may experience side effects such as increased heart rate, facial redness, lower limb edema, and gingival hyperplasia. short-acting nifedipine is generally not recommended for patients with acute coronary syndrome.
Clinically used non-dihydropyridine calcium antagonists mainly include verapamil and diltiazem, which can also be used for antihypertensive treatment.
b. Angiotensin-converting enzyme inhibitors ACEI: commonly used drugs include captopril, enalapril, benazepril, ramipril, perindopril, etc. They are especially suitable for patients with chronic heart failure, post-myocardial infarction with cardiac insufficiency, diabetic nephropathy, non-diabetic nephropathy, metabolic syndrome, proteinuria or microalbuminuria. Contraindications include bilateral renal artery stenosis, hyperkalemia and pregnancy.
c. Angiotensin receptor antagonist ARB: commonly used drugs include crosartan, valsartan, irbesartan, telmisartan, etc. ARB can reduce the risk of cardiovascular events in patients with hypertension; reduce proteinuria and microalbuminuria in patients with diabetes or renal disease. It is particularly indicated in patients with left ventricular hypertrophy, heart failure, atrial fibrillation prophylaxis, diabetic nephropathy, metabolic syndrome, microalbuminuria or proteinuria, and in patients who cannot tolerate ACEI. Adverse effects are rare, with occasional diarrhea. Long-term application may elevate blood potassium, and changes in blood potassium and creatinine levels should be monitored. Bilateral renal artery stenosis, pregnancy, and hyperkalemia are contraindicated.
d. Diuretics: mainly include thiazide diuretics, tab diuretics, potassium-protective diuretics and aldosterone receptor antagonists. Diuretics used to control blood pressure are mainly thiazide diuretics. In China, the commonly used thiazide diuretics are mainly hydrochlorothiazide and indapamide. Small doses of thiazide diuretics (such as hydrochlorothiazide 6.25-25 mg) have little effect on metabolism and can significantly increase the antihypertensive effect of the latter when combined with other antihypertensive drugs (especially ACEI or ARB). These drugs are particularly indicated in elderly and senior elderly patients with hypertension, systolic hypertension alone or with heart failure, and are also one of the basic drugs for refractory hypertension. The adverse effects are closely related to the dose, so small doses should usually be used.
Potassium-preserving diuretics such as amiloride and aldosterone receptor antagonists such as spironolactone are sometimes used to control blood pressure. The risk of hyperkalemia should be borne in mind when combined with other potassium-preserving antihypertensive agents such as ACEI or ARB. Long-term application of spironolactone may lead to gynecomastia and other adverse effects.
e. Betablockers: Commonly used drugs include metoprolol, bisoprolol, carvedilol and atenolol. Betablockers are particularly suitable for patients with tachyarrhythmia, coronary angina, chronic heart failure, increased sympathetic activity, and hypertension in a hyperdynamic state. The sudden discontinuation of long-term use of the drug can occur rebound phenomenon, that is, the original symptoms aggravate or appear new manifestations, more common are rebound blood pressure, accompanied by headache, anxiety, etc., called withdrawal syndrome.
f, alpha-blockers: commonly used drugs are Gottlieb, Terazosin, Tamsulosin, for hypertension with prostatic hyperplasia patients, also used in the treatment of refractory hypertensive patients, the start of medication should be before going to sleep, to prevent postural hypotension, the use of attention to the measurement of blood pressure in the sitting position, preferably using controlled-release preparations. It is contraindicated in patients with postural hypotension. Use with caution in cases of heart failure.
g. Centrally acting drugs: including colistin, reserpine, methyldopa. Colistin is used for renal insufficiency uremia or refractory hypertension, with the side effect of slowing down the heart rate; reserpine has been used sparingly; methyldopa is used for the treatment of hypertension in pregnancy, with attention to the side effects of liver function.
h, renin inhibitors: a new class of antihypertensive drugs, whose representative is Aliskiren, can significantly reduce the blood pressure level of hypertensive patients, but the impact on cardiovascular and cerebrovascular events has yet to be evaluated in large-scale clinical trials.
3.Drug reduction
Patients with hypertension are generally required to be treated for life. Patients diagnosed with hypertension who discontinue their medication will eventually return to pre-treatment levels (either later or sooner). However, patients whose blood pressure is under long-term control may attempt to carefully and gradually reduce the number of doses or doses of medication. This is especially true for patients who are carefully treated with non-pharmacologic therapy and who are closely monitoring the progress and effects of lifestyle improvements. Patients should monitor their blood pressure very carefully when trying this “tapering”.
4.Integrated intervention of multiple risk factors
Patients with hypertension often have multiple risk components for cardiovascular disease, including risk factors, coexisting target organ damage, and concomitant clinical disorders. In addition to interventions for a particular risk component, more emphasis should be placed on integrated interventions for multiple risk components. Comprehensive interventions are conducive to comprehensive control of cardiovascular risk factors, early prevention of cardiovascular disease, and blood pressure control. The measures of comprehensive intervention for hypertensive patients are multifaceted, commonly used are antihypertensive, lipid regulation, treatment of constipation, treatment of mental tension, treatment of insomnia, antithrombotic therapy; for people with folic acid deficiency, folic acid supplementation; for diabetic patients, blood glucose control. The goal of preventing the occurrence of cardiovascular and cerebrovascular diseases is achieved by controlling multiple risk factors, protecting target organs, and treating diagnosed diabetes mellitus and other disorders.