How to reasonably choose blood pressure lowering drugs for patients with hypertension
Patients with hypertension need long-term standardized medication to truly and effectively control hypertension. How to reasonably choose antihypertensive drugs is particularly important for patients with hypertension.
A. Which patients need blood pressure lowering medication
Before diagnosing hypertension, it is important to exclude secondary hypertension. Secondary hypertension accounts for about 5% of all hypertension. Such as primary aldosteronism, pheochromocytoma, cortisolism, renal vascular hypertension, renal parenchymal hypertension, renin secretory tumor, etc. What we normally call hypertension refers to primary hypertension.
The targets of antihypertensive drug treatment include.
1.Patients with hypertension grade 2 or above;
2, hypertension combined with diabetes mellitus, or already have heart, brain, kidney target organ damage or complications patients;
3. Anyone whose blood pressure is persistently elevated and has not been effectively controlled after improving lifestyle. From the perspective of cardiovascular risk stratification, high-risk and very high-risk patients must be treated intensively with blood pressure-lowering drugs.
Second, the basic principles of the application of antihypertensive drugs
The use of antihypertensive drugs should follow the following four principles, namely, starting with small doses, giving preference to long-acting agents, combined medication and individualization.
1.Start with small doses
In order to reduce the side effects of drugs and to find out their sensitivity and adaptability to drugs, the smallest effective dose should be used at the beginning, especially for the elderly, who must start with a small dose. If the blood pressure control is poor and no adverse reactions, then gradually add to the regular dose or individual effective dose.
2. Give preference to long-acting preparations
As far as possible, use long-acting drugs that are given once a day and have a continuous 24-hour antihypertensive effect, so as to effectively control nighttime blood pressure and morning peak blood pressure. More effective prevention of cardiovascular and cerebrovascular complications. If you use short-acting or medium-acting preparations, you need to give the drug 2-3 times to achieve the purpose of smooth blood pressure control.
3.Rational combined medication
Reasonable combination medication can reduce drug toxic side effects and achieve the best antihypertensive effect. When blood pressure control is unsatisfactory, priority should be given to adding a small dose of another class of drugs, rather than increasing the dose of drugs already in use, much less adding similar antihypertensive drugs.
4.Individualization
According to the patient’s specific situation, drug effectiveness and drug resistance, taking into account the patient’s economic conditions and personal wishes, choose the appropriate antihypertensive drugs for the patient.
In the process of applying antihypertensive drugs, do not frequently change different antihypertensive drugs. The onset of action time and peak time of antihypertensive drugs vary. Long-acting preparations are slow to reach the peak time, we must wait patiently and carefully observe the efficacy and side effects, frequent drug changes may miss good antihypertensive drugs, delaying treatment time. After the consolidation of drug efficacy, generally do not need to change drugs, not to mention the random addition and sudden discontinuation of drugs.
Three, antihypertensive drug types
1, diuretics: currently the most commonly used clinical thiazide diuretics, mainly dihydrocoumaric acid and indapamide. The onset of antihypertensive effect is relatively smooth, slow, relatively long duration and long-lasting effect. It is suitable for patients with mild to moderate hypertension, high systolic blood pressure, obesity or concomitant cardiac insufficiency. Due to the effect of interfering with glucose and lipid metabolism and inducing hyperuricemia, it should be used with caution for patients with diabetes, hyperlipidemia and gout, and attention should be paid to electrolyte disorders.
2, beta-blockers: more clinical applications are bisoprolol, sotalol, metoprolol and carvedilol, suitable for young and middle-aged patients with rapid heart rate (80 beats/min), especially for patients with high renin activity with angina pectoris or post-myocardial infarction and supraventricular tachyarrhythmia, whose side effects are interference with glucose and lipid metabolism and induction of hyperuricemia, for patients with heart block, asthma and peripheral The side effects are interference with glucose metabolism and induction of hyperuricemia, which are contraindicated in patients with heart block, asthma and peripheral vascular disease, and sudden discontinuation of the drug will cause rebound increase in blood pressure, headache, anxiety, sweating and other withdrawal syndrome.
3, calcium channel blockers: the advantage of this class of drugs is reliable antihypertensive and does not interfere with sugar and lipid metabolism, especially for elderly hypertension with angina pectoris, peripheral vascular disease, diabetes mellitus, hypertension during pregnancy and combined with renal damage patients, the commonly used drugs are nifedipine, felodipine, amlodipine, the adverse effects of vasodilatation caused by headache, facial flushing and ankle edema.
4, angiotensin-converting enzyme inhibitor (ACEI): clinically indicated for hypertension with left ventricular hypertrophy, cardiac insufficiency, diabetes mellitus and renal insufficiency (blood creatinine <3mg/L) patients, and the drug has no effect on glucolipid metabolism, its side effects are irritating dry cough, hyperkalemia, abnormal taste and angioneurotic edema, due to the risk of teratogenicity, generally not used in pregnant women, clinically used The drugs commonly used in clinical practice are captopril, enalapril, benazepril and fosinopril.
5, angiotensin receptor antagonist: its hypotensive, cardioprotective and renal aspects are similar to ACEI, the onset of antihypertensive effect is slow, but long-lasting and smooth. The most important feature of this drug is that there are fewer adverse reactions directly related to the drug, which does not cause irritating dry cough, still has the effect of lowering blood uric acid, and high compliance with continuous treatment. Treatment targets and contraindications are the same as for ACEI. Commonly used clinically are losartan, irbesartan and irbesartan.
6, alpha-blockers: the drug has no effect on blood glucose metabolism and can improve lipid metabolism and prostatic hyperplasia patients with difficult urination symptoms, clinical especially for hypertensive patients with hyperlipidemia and prostatic hypertrophy, the commonly used drugs are prazosin, terazosin and doxazosin, its common side effects are due to the reduction of venous blood return, common postural hypotension, palpitations and syncope, etc.
IV. Blood pressure control target values
The target of blood pressure control in hypertensive patients is 140/90 mmHg for the general population and 130/80 mmHg for patients with diabetes or renal disease. for elderly patients with systolic hypertension, systolic blood pressure is controlled below 150 mmHg and can be reduced to below 140 mmHg if tolerated. Blood pressure should be lowered to these target blood pressure levels as early as possible, but not as soon as possible. In most patients with hypertension, blood pressure should be lowered gradually to the target level over a period of weeks to months, depending on the condition.
Younger patients with a shorter course of hypertension can reach the target sooner. However, elderly patients, patients with longer duration of disease or those with target organ damage or complications should lower their blood pressure moderately slowly.
V. Antihypertensive treatment plan
The combined application of antihypertensive drugs has been recognized as a better and reasonable treatment plan, which is conducive to complementing the strengths of antihypertensive drugs and reducing or offsetting the adverse effects of certain antihypertensive drugs. It is important to remind the majority of patients that hypertension is one aspect of blood pressure lowering, but the important thing is the protection of target organs (heart, brain, kidney and peripheral blood vessels).
Most patients without complications can use thiazide diuretics, beta-blockers, CCB, ACEI, ARB alone or in combination, and treatment should start with small doses.
The main recommended clinical application of optimal combination therapy regimen in China is.
ACEI/ARB+ dihydropyridine CCB
ACEI/ARB+ thiazide diuretics
Dihydropyridine CCB + thiazide diuretics
Dihydropyridine CCB + beta-blocker