, One of three drugs should be diuretics. Patients with high blood pressure and controlled by four or more drugs is considered to have high arterial tension intractable.
The goal of the therapeutic value of blood pressure is 140/90 mm Hg in people middle-dangerous attack, and must be less than that in patients with atherosclerosis, diabetes and chronic kidney disease patients.
General principles:
Approved the recommendations contained evidence of the American Society of Cardiology AHA in 2008 Almaaljtin that both pharmacological and non-drug for high blood pressure Almand guaranteed.
* Determine the height of tension and treatment of secondary blood:
Identifying and addressing the root causes of curable hypertension secondary component in the treatment of essential hypertension Almand; is Aloldostronah primary and renal artery stenosis of the most common of these reasons.
Which inspired a number of key clinical, including hypertension Almand, the possibility of a high tension secondary more than primary hypertension; must therefore be taken into account in all patients with high blood pressure Almand.
* Stop the drugs that raise blood pressure:
There are many drugs that can raise blood pressure and thus increase the height of deep tension is worse, the most common of these anti-inflammatory drugs (NSAIDs) NSAIDs; must therefore be possible to stop treatment when such medication or reduce dosage.
The participation of the patient to monitor his blood pressure at home may serve to increase control over this situation.
The high arterial tension Almand side effects caused by real or acquired many of the antihypertensive drugs most difficult cases, a cure.
* Refer the patient to a specialist in hypertension:
If the suspicion due to a secondary specific to the high pressure in a patient with hypertension Almand advised to refer it to the appropriate specialist physician.
It is recommended that it be referred, too, if blood pressure remained high after six months of treatment despite the absence of any secondary cause suspected as a reason for this rise.
* Mobile monitoring of blood pressure Ambulatory BP monitoring:
Should assess patients for blood pressure measurements are used outside the clinic, so that pressure is recorded in the home; or be the initial evaluation through monitoring mobile access to more effective treatment. And help us sphygmomanometers used outside the clinic in the discrimination of high pressure caused by the white robe syndrome. The best measurements of ambulatory pressure gauges used in the clinic to predict cardiovascular morbidity (damage to the terminal users, for example) and predict the mortality rate of patients with high blood pressure Almand.
Non-drug treatment:
Be a useful pharmacological treatment is usually in patients with hypertension Almand.
The main therapeutic means include low-salt diet and weight loss in obese patients and overweight, moderation in alcohol intake.
Because to achieve permanent changes in the diet is difficult, it is advisable to resort to direct a professional and follow up with a specialist in the diet, or dietitian documented.
Drug treatment:
Apply this treatment to patients with high blood pressure Almand, who did not register with any secondary causes of hypertension.
Include drug treatment for hypertension Almand definition of the integration of three drugs or more, including a diuretic.
It must be a selection of these three vehicles tailored to each patient; has taken into account the benefit of treatment or previous precedents for possible adverse effects or the financial or the presence of disease Kalqsour accompany chronic renal disease and diabetes.
Should be used as vehicles to influence longevity and simplification of dosage regimen as possible in order to reduce the number of pills prescribed and to provide a dose, just one day; as difficult to comply with treatment when the increased use of grain and complexity of the dosage regimen and financial expenditure, and should discuss the adverse effects of drugs and reduce side effects for Using the calibration of the chemical agent that causes it or replace it.
• Diuretics:
The expansion of the volume of fluid constant (which is not enough to form edema) lead to high arterial tension intractable even when patients taking doses of routinely generating urinary thiazide; this is what was illustrated in a study on 279 patients high blood pressure Almand, and 85% of them taking thiazide.
The levels of brain and atrial Albbtidin Tarahin sodium significantly higher in patients with hypertension Almand, suggesting that a volumetric expansion of liquids.
The use of diuretic effectively is usually necessary to control blood pressure in patients with hypertension Almand. Must also be calibrated diuretics even access to the blood pressure required, or access to the maximum dose permitted by, or when there are adverse effects on the patient related to these diuretics Kaltab or pressure drop erectile tissue or ischemia, as reflected by the increase is not justified in the blood urea nitrogen and / or high concentration of creatinine in serum.
Preferably Klorthaledon hydrochlorothiazide in the treatment of high tension Almand; where it appears that Klorthaledon have a hypotensive effect is more effective than hydrochlorothiazide in part because the half-life much longer.
Most studies that compared Klorthaledon Bhedrokruthiazad evaluated high tension mild to moderate patients. The limited data that Klorthaledon also has a relatively greater benefit in patients with high tension Almand.
In general, treatment starts with Pklorthaledon dose of 12.5 mg per day, which requires splitting the 25 mg pill in half, then continue treatment until a subsequent calibration of access to a dose of 25 mg per day.
For patients who were previously subjected to treatment Bhedrokruthiazad, treatment is stopped and replaced by Pklorthaledon.
Longer necessary to monitor serum ions, and may be hypokalemia Hypokalemia most common problem in patients with hypertension Almand, is likely to be at least partly the reason is the high levels of aldosterone and patients that explain the rise in tension in response to anti-aldosterone Almand.
Occurs the loss of potassium in the urine when the patient is stable in a specific dose in the two weeks or three weeks, only the first treatment; and then keep the patient in stable condition where the serum potassium at a constant level but less than the fundamental value, if we assume the absence of significant changes in the system food or taking other drugs affect the balance of potassium (of these drugs and anti-angiotensin inhibitors, aldosterone).
And thiazide diuretics are less effective in patients who have a record of glomerular filtration rate less than 30 ml / min per m 2, and may be loop diuretics and Kalvorsimid Altursimid necessary to achieve effective control of the volume of fluid involved.
The Vorsimid a relatively short duration of effect, and usually requires two doses of it at least daily, while it is Altursimid loop diuretic with a longer duration of effect and better absorption may be easier to use but more expensive.
• Anti-aldosterone:
Include anti-aldosterone mineralocorticoid receptor antagonists (Sbernolambron and Aebleranon) diuretics and urinary potassium to the clipboard (including amiloride and Trellamitrin), which surround the level of sodium channels in the collecting tubules that are open as normal due to the secretion of aldosterone.
Believes Sbernolambron and Aebleranon great benefit in reducing the pressure when added to the system of multiple drugs used in patients with high tension Almand; may indicate this effect to the levels of aldosterone elevated significantly in these patients compared with individuals with normal pressure or with high tension controlled by one or two medicines.
Has shown how much this effect in the experience of Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), which conducted the experiment on the 1411 patients was hypertension drugs observers have three antihypertensive (blood pressure 157/85 mm Hg average, the level of the average baseline serum potassium 4.2 mg eq / liter).
When added as a medicine Sbernolambron fourth (intermediate dose of 25 mg per day) associated with lower blood pressure by 22/10 mm Hg, after years of follow-up time. This interest in reducing the pressure Omentha mineralocorticoid receptor antagonists are not predicted by plasma aldosterone levels or in the urine.
The total rise in the average serum potassium level of 0.4 mg eq / liter, as hyperkalemia hyperkalemia at 4% of patients (potassium levels have more than 5.5 mg equivalent / l).
Been described a similar benefit in reducing pressure in patients with hypertension when using Aebleranon Almand and amiloride.
And should monitor patients being treated with anti-aldosterone fear that develops hyperkalemia have; where the increase risk in patients with chronic kidney failure and in patients also treated with inhibitors of angiotensin converting enzyme and angiotensin receptor blockers and NSAIDs NSAIDs.
Choose the appropriate treatment regime:
The rules of the following patients with high blood pressure Almand, who did not register with any secondary causes of hypertension, or indications of a certain category of drug (such as beta-blockers is contraindicated or calcium channel blockers is Aldehedruperedanah and to control the rate of atrial fibrillation).
Few studies have evaluated the importance of the participation of three or more of the drugs used to treat high blood pressure Almand. The approach taken in this study depends on the combination in sequence between the means are different mechanisms of action. Expressed tripartite partnership between the inhibitors of angiotensin-converting enzyme 1, or angiotensin receptor blockers and calcium channel blockers influence Aldehedruperedanah long (preferably Amlodipine) and thiazide diuretics influence long (preferably Klorthaledon) effective and well tolerated in many patients with high blood pressure Almand.
The Sbrinolambron usually be given in patients with hypertension uncontrolled and have already treated one of three pharmaceutical Posts (on a three-drug). Preferred starting dose of 12.5 mg / day (requires splitting the 25 mg pill in half) before increasing to 25 or even 50-mg / day if the need arises. Reflected by the side effects of breast tenderness and gynecomastia and erectile dysfunction and in high doses. In general, should not exceed Sbrinolambron dose of 50 mg per day when you are not sure of the existence of an initial Oldostronah clear.
It also addresses some of the system, three-drug patients, but also different from the previous preferred system, and the author of angiotensin inhibitors 1 and calcium channel blockers Aldehedruperedanah long influence and thiazide diuretics long impact. This system differs from patient to patient:
If the patient was on hydrochlorothiazide, replaced by Kruthaledon.
If the protocol did not include a given drug from the drug varieties of the three recommended; we added and we respond, or stop any medicine as long as it holds a good, before achieving control of blood pressure.
If the patient still suffers from high blood pressure, additional medication is given, respectively, and particularly those factors include the impact of central Khaasrat beta and can be added as well as vascular stents. And found that giving beta-blockers (eclecticism) that impact such as the expanded vascular Apittalol believes a stronger effect to reduce pressure, and that with fewer side effects compared with traditional beta-blockers, especially in high doses.
Despite the effectiveness of the central factors in reducing the influence of pressure, but side effects are common, it still few studies. General, if we choose to give them drugs to influence longevity, such as clonidine or guanfacine in the label instead of the leather short-term medications that require multiple doses.
Longer stents Vascular effective Kalmennoxedel the best option for patients who are still suffering from high blood pressure, although they follow the protocol before, but it often causes Ahtbac fluid and accelerate in a heartbeat and that calls _ often _ address associated with Bmdarat loop and beta-blockers, respectively. And also cause hirsutism, which is a problem when women Vistbdl then to hydralazine.
Experimental treatments:
The frequency of radiological sabotage, using a catheter, and the electric excitement of the pressure receptors in the carotid sinus in the treatment of which is currently being evaluated feasibility
Radiological sabotage frequencies using the catheter:
This treatment works to reduce blood pressure in patients with hypertension Almand. In a study installed was assessed 50 patients, high blood pressure Almand treated with three or more antihypertensive medications reaching their pressure systolic <160 mm Hg (mean 177/101 mm Hg), and found that 39 out of 45 patients who underwent denervation using a catheter pressure drops systolic they have for more than 10 mm Hg, while blood pressure dropped an average of 14/10 mm Hg in one month, and for the 27/17 year. On the other hand suffered five others - who did not have to sabotage the sympathetic innervation to anatomical reasons - the rise in blood pressure was an average of 26/17 mm Hg during the nine months.
Electrical excitation of pressure receptors in the carotid sinus:
This is where the exciting reflex pressure by altering receptor pressure in the carotid sinus to be able to reduce pressure in patients with hypertension Almand, and study monitoring conducted by the Food and Drug Administration FDA, has undergone ten of the patients blood pressure Almand to plant your work to send electrical impulses to induce reflex pressure in the carotid sinus, which showed the second phase of this study, a decrease in systolic pressure was 41 mm Hg, and in another study registered a decline of 32 mm Hg.
Warning:
Patients with high blood pressure Almand more susceptible to a chronic infection in certain members, as they are at risk of stroke and myocardial infarction and / or heart failure, compared with patients with high blood pressure which can be adjusted easily.
The risk of cardiovascular partially attributed to high blood pressure long-range, controlled well, in addition to the presence of other risk factors include the magnitude of the left ventricle, obesity, diabetes, hyperlipemia, lack of chronic kidney and Nob apnea obstructive.
Conclusion and recommendations:
* Non-drug treatment:
Include non-drug therapeutic methods to identify and reverse the predisposing factors for hypertension, including the application of measures to reduce weight in obese Ktkulail and attendance at exercise and a diet low in salt, as well as a moderate intake of alcohol. In the case of secondary causes of hypertension, it is best to refer patients to appropriate specialist for treatment, some of them suffer _ _ For example, episodes of obstructive apnea during sleep, and should also avoid giving drugs that contribute to high blood pressure as much as possible.
• taking secondary causes of high pressure into account, and address, if any,
* Drug treatment:
Include therapeutic pharmaceutical means of partnership between three or more antihypertensive medications (which are different mechanisms). We must not lose sight of the existence of indications drug binding to a particular class of drugs but not others (such as beta blockers or calcium channel blockers is Aldehedruperedanah to control the rate of atrial fibrillation), but if there was no indication for a class of medications, it is preferable application of the drug trio of ( three-drug following):
enzyme inhibitors, angiotensin-generator 1 or angiotensin receptor blockers.
calcium channel blockers such as the impact of long Alomilodben
thiazide diuretics influence long, preferably chlorthalidone.
With attention to patients with glomerular filtration rate was estimated to have less than 30 ml / min / m 2; preferably given loop diuretics Kalfosmd Altursimid or thiazide diuretics on the long influence, in order to achieve effective control of the volume of fluid involved.
* When patients who suffer from high blood pressure is uncontrolled in spite of constantly giving them the precise dosages of the three previous post, then add the recommended Spirolambron (class 2B). Usually start with a dose of 12.5 mg / day dose is calibrated for later access for up to 25 or 50 mg / day, with attention to not exceed the dose of 50 mg / day in the absence of an initial Oldostronah clear. It is also important when using chlorthalidone with Sbarulakton calibrate the level of serum potassium and attention to any increase or decrease in the level. Patients who did not show tolerance to Spirolambron, it is advisable to replace it and Eppleranon Omiloraad.
- If you are still suffering from hypertension, it is proposed then to add a beta blocker (eclecticism) extended to vessels such as labetalol (type 2C), alternatives include drugs such as the central influence guanfacine or clonidine in the leather label.
- The direct vascular dilators such as hydralazine and minoxidil for women for men to share with beta blockers and loop diuretics, the protocol (option), the last of those who did not see real improvement over previous processors.
* Addresses some of the patients with arterial tension Almand three-drug system, a different preferred system for the former consisting of inhibitors of angiotensin 1 and calcium channel blockers Aldehedruperedanah long influence and thiazide diuretics long impact. This system differs from patient to patient:
- If the patient was on hydrochlorothiazide, to alter Kruthaledon.
- If the protocol did not include a given drug from the drug varieties of the three recommended; we added and we respond, or stop any medicine as long as it holds a good, before achieving blood pressure control.
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