Patients with hypertension are two to four times more likely to have combined coronary heart disease than non-hypertensive individuals. In the 1980s, antihypertensive therapy was applied to prevent the development of coronary heart disease in hypertensive patients. Coronary heart disease often manifests as angina pectoris, myocardial infarction, arrhythmia, heart failure or sudden death.
When hypertension is combined with coronary artery disease, the target pressure is 130/80 mmHg and the diastolic pressure should not be lower than 60 mmHg, otherwise it will aggravate myocardial ischemia. Angina pectoris or myocardial infarction is likely to occur. In patients with coronary heart failure, the target pressure should be 120/80 mm Hg. When choosing antihypertensive drugs for patients with hypertension combined with coronary heart disease, the prevention of atherosclerosis, angina pectoris or myocardial infarction should be taken into account. Patients who have had angina or myocardial infarction should preferably choose beta-blockers, calcium channel blockers or angiotensin converting enzyme inhibitors, which can effectively lower blood pressure and reduce the incidence of myocardial infarction again. Calcium channel blockers are superior to angiotensin-converting enzyme inhibitors in reducing angina pectoris or myocardial infarction in patients with coronary artery disease. In improving carotid atherosclerosis, delaying carotid thickening and plaque progression in coronary arteries, long-term application of calcium channel blockers is better than diuretics, beta-blockers or angiotensin converting enzyme inhibitors; while angiotensin converting enzyme inhibitors can be used in various patients with coronary artery disease, and are better than other drugs in improving myocardial remodeling, reversing myocardial hypertrophy and protecting myocardium, and are an important choice for hypertension combined with coronary artery disease. It is an important drug for patients with hypertension combined with coronary heart disease to choose to lower blood pressure.
1.Angina pectoris
Patients with hypertension combined with coronary angina should lower their blood pressure slowly to prevent deterioration of myocardial ischemia and worsening of symptoms. The ideal antihypertensive drug can increase coronary blood flow, reduce the left ventricular load and lower myocardial oxygen consumption.
For patients with hypertension combined with coronary artery disease, β-blockers (such as carvedilol, long-acting metoprolol or atenolol), long-acting calcium channel blockers (such as bethanechol, amlodipine, etc.), angiotensin-converting enzyme inhibitors (such as benazepril, perindopril, enalapril, lenopril, captopril), angiotensin II receptor blockers (colesartan, valsartan, etc.) and angiotensin II receptor blockers (valsartan, etc.) are recommended to improve myocardial ischemia in coronary artery disease. Valsartan, etc.) and nitrates. Generally, the blood concentration reaches the steady state in 7-10 days, and the routine application after the steady state can maintain the effective dilatation of coronary vessels for 24 hours, which is conducive to the control of myocardial ischemia at night and early in the morning. Hypertension combined with coronary angina, if necessary, can also choose alpha-blockers (such as prazosin, terazosin, etc.) or indapamide, liupamide benzathine for antihypertensive treatment.
Beta-blockers reduce myocardial oxygen consumption through negative inotropic effects and reduce exertional angina attacks, and are the drug of choice for patients with hypertension combined with coronary angina, especially for patients with angina with hyperdynamic status. Calcium channel blockers dilate peripheral arteries, reduce anterior and posterior cardiac load, decrease myocardial oxygen consumption, dilate coronary vessels, and increase coronary blood flow, which meet the conditions of ideal antihypertensive drugs. Angiotensin-converting enzyme inhibitors are ideal antihypertensive drugs for patients with coronary angina because they can lower blood pressure while maintaining cardiac blood flow without increasing heart rate and can improve long-term prognosis of patients with coronary heart disease.
The antihypertensive drugs such as long-pressin, reserpine and hydrazinepyridazine can excite the sympathetic nervous system and the angiotensin system, releasing catecholamines and inducing or aggravating angina pectoris. Hypertension combined with angina pectoris in patients with coronary artery disease is prohibited.
2, acute myocardial infarction
The target blood pressure for hypertensive patients with acute myocardial infarction is 140/90 mmHg. β-blockers and angiotensin converting enzyme inhibitors are preferred in hypertensive patients with previous myocardial infarction. β-blockers (e.g. metoprolol) have a protective effect on the myocardium. Early application of β-blockers in acute myocardial infarction can narrow the infarct, prevent reinfarction and sudden death, and reduce the reinfarction rate and cardiovascular mortality by about 25% in patients with acute myocardial infarction. The priority indication for angiotensin-converting enzyme inhibitors for antihypertensive therapy is late myocardial infarction, which can protect ischemic myocardium, reduce infarct size, reduce complications of acute myocardial infarction and decrease the morbidity and mortality rate. In the prevention of myocardial infarction, angiotensin-converting enzyme inhibitors are similar to the calcium-channel blocker amlodipine.
The calcium channel blocker diltiazem may reduce the rate of death in patients with myocardial infarction. In hypertension combined with acute myocardial infarction and heart failure, the application of nitroglycerin or sodium nitroprusside can improve myocardial ischemia and relieve symptoms. The combined application of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers is not currently advocated to protect the myocardium.
3.Cardiac arrhythmia
The arrhythmia of hypertension combined with coronary artery disease is divided into two kinds of slow arrhythmias and rapid arrhythmias.
When combined with slow arrhythmias, antihypertensive drugs that can increase the heart rate (such as nitroglycerin, nifedipine, angiotensin-converting enzyme inhibitors and diuretics, etc.) should be used. Non-dihydropyridine calcium channel blockers (verapamil, diltiazem), methyldopa or colistin can slow down the heart rate while lowering the blood pressure and should be disabled.
Beta-blockers (e.g., bisoprolol) and carvedilol (also known as Darifen or Jinluo), which have alpha and beta-blocking effects, can be used in patients with hypertension who are at risk of sudden death from ventricular fibrillation. The calcium channel blocker verapamil can also be used as the drug of choice for hypertension combined with tachyarrhythmias, but should not be used with beta-blockers because of the risk of severe hypotension, heart block, or cardiac arrest.
Closantan (or valsartan) can significantly prevent the occurrence of atrial fibrillation in hypertensive patients and significantly reduce the occurrence of cardiovascular events in hypertensive patients with atrial fibrillation than atenolol.
4.Heart failure
The target blood pressure for patients with hypertension combined with coronary heart failure should be less than 130/80 mm Hg. Domestic and international guidelines for the management of heart failure emphasize that diuretics, angiotensin-converting enzyme inhibitors and beta-blockers are the cornerstones of the treatment of hypertension combined with heart failure.
Diuretic antihypertensive drugs (e.g., dihydroketorolac, anisodone, etc.) are suitable for patients with chronic systolic heart failure, and should be used with caution in diastolic heart failure. Intermittent application of small doses of diuretic-type antihypertensive drugs can control blood pressure while relieving the edema of heart failure. The aldosterone antagonist spironolactone can prolong the survival of patients with hypertension combined with edema and hypokalemia in chronic heart failure and reduce their morbidity and mortality.
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers reduce cardiac anteroposterior load and improve cardiac output and myocardial contractility. They reduce the morbidity and mortality of patients with chronic heart failure, the incidence of cardiovascular events (such as angina pectoris in patients with coronary artery disease) and effectively prevent heart failure, and can be the first choice for the treatment of chronic systolic heart failure, but require long-term application. Patients who cannot tolerate angiotensin-converting enzyme inhibitors can be switched to angiotensin II receptor blockers.
In theory, β-blockers are effective in patients with diastolic heart failure because of their anti-sympathetic activity and other effects, which can reduce the rate of death and rehospitalization in patients with heart failure. However, due to the strong inhibitory effect of β-blockers on myocardial contractility, their initial application should be cautious. When there are obvious indications, it is also necessary to start with small doses and to closely observe changes in the condition during treatment.
Long-term application of angiotensin-converting enzyme inhibitors and small doses of β-blockers in the treatment of hypertension combined with heart failure patients can achieve the purpose of prolonging survival and reducing the rate of death. β-blockers for patients once adapted, should continue to increase the dose (for example, betalactam 25mg, twice a day) until the patient tolerated, and adhere to long-term use, and not to interrupt treatment, interruption of treatment patients Heart failure will rebound and aggravate the condition.
Calcium channel blockers nifedipine controlled-release tablets (Bison) reduce cardiac afterload by dilating small arteries, and calcium channel blockers (mainly accused of releasing tablets) may be beneficial in patients with mild chronic heart failure in essential hypertension, but evidence-based medicine has shown that calcium channel blockers often worsen the condition in patients with severe heart failure. Currently, calcium channel blockers are not considered beneficial in severe chronic heart failure and should be used with caution.
Direct vasodilators (e.g., prazosin, long-pressin, hydrazinepyridazine, etc.) are effective in prolonging survival time in patients with hypertension combined with heart failure. Prazosin can reduce the pre and afterload of the heart and has good effect on hypertension combined with chronic heart failure, especially in some patients with refractory heart failure, but long-term application is likely to lead to fluid retention and requires the addition of diuretics. Although the combination of hydrazinopyridazine and nitrates can reduce the death rate of patients with chronic heart failure, the long-term application of adverse effects is large and not easily tolerated.
If atrial fibrillation occurs after the onset of heart failure in hypertensive patients compared with those with or without prior atrial fibrillation, the length of hospitalization and in-hospital morbidity and mortality rates are significantly longer and the prognosis is poorer.
To summarize.
1. For patients with coronary artery disease in all conditions, angiotensin-converting enzyme inhibitors are generally appropriate. Patients with hypertension should choose antihypertensive drugs that have both antihypertensive and anti-cardiac effects for treatment, and angiotensin-converting enzyme inhibitors can achieve dual effects. Enalapril is an angiotensin-converting enzyme inhibitor, and its antihypertensive effect is 8 times higher than that of captopril, which is a representative drug of the same kind. This drug not only has a strong antihypertensive effect, but also has a long half-life and a long-lasting effect, and the price is cheap among the same kind, so it is suitable for application in the primary level. In addition, enalapril has no significant effect on blood glucose, uric acid and lipid levels (those with increased uric acid can be replaced by cloxacin, which can reduce uric acid). It can be used both alone and in combination with other antihypertensive drugs with high compliance. In addition to its antihypertensive effect, enalapril also has good effects of improving myocardial remodeling, reversing myocardial hypertrophy and protecting myocardium, which can effectively prevent and treat heart enlargement, heart failure and various cardiac events in patients with coronary artery disease. Therefore, it is one of the ideal antihypertensive drugs for patients with hypertension with coronary artery disease. Apparent side effects such as dry cough can be replaced by angiotensin II receptor blocking drugs such as, Crosartan, Valsartan, etc.
2. Evidence-based medicine proves that long-term application of short-acting calcium channel blockers, such as cardiac painkillers, can increase the overall mortality rate of coronary heart disease, especially unfavorable for patients with severe heart failure. However, in the vast rural and grassroots areas, patients are still widely used this drug to lower blood pressure. The main reason is the cheap price of the drug. But for the principle of the problem, then cheap can not be applied.
3, beta-blockers can reduce myocardial oxygen consumption, effectively relieve angina pectoris, prevent the occurrence of malignant arrhythmias and adverse cardiac events, and reduce the incidence of sudden death from coronary heart disease, for patients with heart failure generally start taking small doses, and be cautious in patients with severe heart failure. For young and middle-aged patients with sympathetic hypertension, the antihypertensive effect is better. beta-blockers are the cornerstone drugs for hypertension combined with coronary artery disease.
4.Patients with hypertension and coronary artery disease often have other risk factors for coronary artery disease, such as smoking, dyslipidemia, diabetes, etc., so attention should be paid to lowering blood pressure and at the same time to the comprehensive management of coexisting risk factors.
5.For patients with hypertension and coronary heart disease with elevated homocysteine, they should actively supplement with folic acid tablets, such as Enalapril folic acid tablets (10.8mg/tablet), one tablet per day. Because patients with hypertension with elevated homocysteine are prone to stroke, and elevated homocysteine is also an independent risk factor for coronary heart disease.