How to rationally and safely use medication in hypertensive patients
Core Tip: Essential hypertension is the most common disease of the cardiovascular system.
1. The reason why hypertension must be actively treated is due to the high disability rate of this disease, which can seriously damage various important organs of the human body.
Hypertrophy of the left ventricle of the heart, increased incidence of coronary heart disease, and ultimately heart failure; cerebrovascular hemorrhage or thrombosis, resulting in new stroke patients every year; kidney damage, renal insufficiency, renal failure, etc.
2. High fatality rate: Patients who die from hypertension and cardiovascular disease account for 41% of the total deaths each year, while untreated hypertensive patients live an average of only 19 years, which is 20 years shorter than that of normotensive patients.
The benefits of hypertension treatment are unexpected: every 2-5 mmHg drop in systolic blood pressure reduces stroke mortality by 6%-14%, coronary heart disease mortality by 4%-9%, and overall mortality 3%-7%.
The treatment of hypertension is divided into two aspects: non-drug therapy and drug therapy.
Non-drug therapy is the basic treatment that all hypertensive patients should follow, and it is also the initial treatment method for low-risk and intermediate-risk patients. Low-risk patients are those with hypertension <160/100 mmHg and no other risk factors; intermediate-risk patients are those with hypertension <180/110 mmHg but with 0-2 other risk factors. (Other risk factors include: 1) age: male > 55 years or female > 65 years; 2) smoking; 3) dyslipidemia: increased total cholesterol or LDL cholesterol; 4) diabetes; 5) family history of premature cardiovascular disease Wait. )
Non-drug treatment includes the following aspects: 1. Reasonable diet - reduce salt intake (<6g per day), reduce fat intake, eat potassium-rich fruits and vegetables (bananas, oranges, rapeseed, amaranth, mushrooms, jujube, etc.), and adequate amount of high-quality protein;
2. Quit smoking and limit alcohol consumption - smoking will significantly increase the risk of hypertensive complications (such as stroke, myocardial infarction, etc.), and reduce or offset the efficacy of antihypertensive treatment, the cardiovascular benefits of smoking cessation after 1 year at any age It can be shown that abstinence and restriction of alcohol can significantly reduce blood pressure;
3. Moderate exercise and weight control - appropriate increase in physical activity (moderate walking, jogging, etc.) can reduce blood pressure by up to 11/6 mmHg in hypertensive patients, and 10% weight loss can reduce systolic blood pressure by 6.6 mmHg.
4. Maintain psychological balance - long-term mental stress is an important cause of hypertension and affects the efficacy of antihypertensive. Patients should take psychological counseling and actively participate in cultural, sports and social activities.
Drug therapy is suitable for high-risk hypertensive patients, that is, those with blood pressure ≥180/110mmHg, or with ≥3 risk factors, or those with heart, brain, kidney, blood vessel, and fundus diseases.
Drug dosage forms are divided into:
1. Short-acting drugs—fast onset, short duration, frequent doses, and large blood pressure fluctuations;
2. Long-acting drugs—sustained-release drugs have uniform efficacy and long maintenance time (some cannot be taken apart), and controlled-release drugs are released evenly, have a long maintenance time, and cannot be taken apart.
Commonly used drugs are:
1. Diuretics: hydrochloride (hydrochlorothiazide), Shoubishan (indapamide), spironolactone (spironolactone), furosemide (furosemide)
2. Beta-blockers: Betaloc (Metoprolol), Kangxin or Bosu (Bisoprolol Fumarate)
3. Calcium channel blockers: [1] 'Dipine' categories: ①Baixintong (nifedipine), Norvox (amlodipine besylate), polidin (felodipine), lorazepine (Lasidipine), etc.; [2] Verapamil (verapamil hydrochloride) [3] Hexinshuang (diltiazem hydrochloride)
4.ACEI ('Puri' class): captopril (captopril), luodingxin (benazepril hydrochloride), mononol (fosinopril sodium), astra (perindopril) )
5. ARBs (‘sartans’): Cozaia (losartan potassium), Diovan (valsartan), Ambovi (irbesartan)
6. Others: α and β receptor blockers: Daliquan (carvedilol), α receptor blockers: Gotrane (terazosin hydrochloride); fixed compound preparation: Beijing Jiangya No. 0 , Compound antihypertensive tablets, etc.
Principles of drug application:
1. Most patients can start treatment with one drug;
2. Start with a small dose and gradually increase the dose;
3. It is not advisable to change the medicine frequently;
4. It is not advisable to reduce or stop the medicine at will;
5. In long-term treatment, a drug taken once a day is better than a drug that needs to be taken multiple times a day;
6. More than half of the patients require combined medication.
monograph on drugs
1. diuretics
Applicable: elderly simple systolic hypertension, obesity, heart failure;
Contraindicated: gout, hyperuricemia;
Use with caution: abnormal serum potassium, renal insufficiency;
2. beta-blockers
Applicable: Fast heart rate, especially with tachyarrhythmia; with coronary heart disease, angina pectoris, myocardial infarction.
Contraindicated: Bronchial asthma, heart block, chronic obstructive pulmonary disease, peripheral vascular disease.
3. calcium channel blockers
[Dipines]—reliable and stable curative effect, suitable for: hypertension of various degrees, the elderly, with coronary heart disease angina pectoris, peripheral vascular disease, pregnancy, with kidney damage;
Adverse reactions: headache, facial flushing, ankle edema, gingival hyperplasia.
Verapamil (verapamil hydrochloride) or Hexinshuang (diltiazem hydrochloride) have good blood pressure lowering effect, but they have side effects such as inhibition of conduction system and constipation.
4. ACEI (Puri) class, with target organ protection.
Applicable to: left ventricular hypertrophy, myocardial infarction, cardiac insufficiency, mild renal damage patients.
Adverse reactions: dry cough (incidence 3%-22%), increased serum potassium, edema, rash, dysgeusia;
Contraindicated: severe renal failure, pregnancy, hyperkalemia, bilateral renal artery stenosis;
5. ARB (Sartan) class
Applicable: Same as ACEI, dry cough occurs less frequently, and Kesuya still has the effect of lowering uric acid;
Adverse reactions: the same as ACEI, other individual patients have abnormal liver function or myalgia;
6.1) Alpha-blockers:
Applicable to: patients with hyperlipidemia or prostatic hypertrophy
Adverse reactions: first-dose orthostatic hypotension, nasal congestion, fatigue;
2) Compound preparations (Beijing Jiangya No. 0, Compound Jiangya Tablets)
Adverse reactions: slow heart rate, depression, ulcers.
The benefits of combination therapy are: 1. Increase the rate of blood pressure control compliance; 2. Reduce the dosage of each drug, reduce the chance of adverse reactions; 3. Learn from each other's strengths to make up for the shortcomings of each drug, while making up for its shortcomings.
How to rationally combine medication?
1. Diuretic-based combination therapy
- Diuretics in combination with ACEIs or ARBs
- Concomitant use of diuretics and beta-blockers
- Concomitant use of diuretics and calcium antagonists
2. Calcium antagonist-based combination therapy
- Calcium antagonists combined with ACEI or ARB
- Combination of calcium antagonists and beta-blockers
- Combination of calcium antagonists and diuretics
Precautions for medication of various patients:
Elderly patients 1. It is not advisable to use too many types of medication, so as not to increase the burden on the liver and kidneys, and closely monitor the liver and kidney functions during the medication. 2. Pay attention to the interaction between drugs for different diseases, and avoid repeated or inappropriate use of drugs; 3. The blood pressure should not drop too fast, and the amplitude should not be too large, so as to avoid insufficient blood supply to organs, especially the brain.
Diabetic patients: The target blood pressure is below 130/80mmHg, and reaching the target blood pressure can reduce the total mortality and the incidence of cardiovascular events by more than 50%-60%.
Benefits of ACEI or ARB in diabetic patients:
It can not only effectively lower blood pressure, but also protect target organs. It has a good effect on left ventricular hypertrophy, myocardial infarction, cardiac insufficiency and delaying renal damage. It has no effect on glucose and lipid metabolism, and can significantly reduce microalbuminuria.
Notes on medication for patients with renal insufficiency: 1. Use long-acting preparations as much as possible to achieve the purpose of stable blood pressure; 2. Antihypertensive target: without affecting renal blood perfusion, when the urine protein is >1.0g/d, the target blood pressure is below 125/75 mmHg, and the target blood pressure is below 130/80 mmHg for those with urine protein <1.0g/d.
Notes on medication for stroke patients: 1. In the acute stage, if the blood pressure of the patient is > 180/105mmHg, blood pressure should be lowered, and the goal is to control the blood pressure at the level of 160-180/90-105mmHg within 1 week; 2. Usually the blood pressure target is <150/100mmHg. Because the blood pressure is too fast or excessive, the cerebral blood perfusion will be significantly reduced, thereby aggravating brain dysfunction.