Essential primary hypertension clinical guidelines. National guidelines for the diagnosis and treatment of arterial hypertension

28.08.2018

On June 9, within the framework of the Congress of the European Society for the Study of Arterial Hypertension (ESH), a draft of new ESH / ESC Guidelines for the treatment of arterial hypertension (AH) was presented, which will make significant changes in approaches to the treatment of patients with hypertension.

Definition and classification of hypertension

The ESH / ESC experts decided to leave the previous recommendations unchanged and classify blood pressure (BP) depending on the level recorded during the “office” measurement (i.e., measurement by a doctor at a clinic appointment), into “optimal”, “normal ”, “high normal” and 3 degrees of hypertension (recommendation grade I, level of evidence C). In this case, AH is defined as an increase in "office" systolic blood pressure (SBP) ≥140 mm Hg. Art. and/or diastolic blood pressure (DBP) ≥90 mm Hg. Art.

However, given the importance of out-of-office BP measurement and differences in BP levels in patients with different methods The ESH/ESC Recommendation for the Treatment of Hypertension (2018) includes a classification of reference blood pressure levels for the classification of hypertension using "home" self-measurement and ambulatory blood pressure monitoring (AMAD) (Table 1).

The introduction of this classification makes it possible to diagnose hypertension based on out-of-office measurement of blood pressure levels, as well as various clinical forms Hypertension, primarily "masked hypertension" and "masked normotension" (white coat hypertension).

Diagnostics

To make a diagnosis of hypertension, the doctor is recommended to re-measure blood pressure “in the office” according to the method that has not changed, or to evaluate the “out of office” measurement of blood pressure (home self-measurement or AMAD) if it is organizationally and economically feasible. Thus, while in-office measurement is recommended for screening for hypertension, out-of-office BP measurements can be used to make a diagnosis. Out-of-office measurement of blood pressure (home self-measurement and/or AMAD) is recommended in certain clinical situations (Table 2).

In addition, AMAD is recommended to assess the level of blood pressure at night and the degree of its decrease (in patients with sleep apnea, diabetes(DM), chronic kidney disease (CKD), endocrine forms of hypertension, impaired autonomic regulation, etc.).

During the screening re-measurement“office” blood pressure, depending on the result obtained, the ESH/ESC Guidelines for the treatment of hypertension (2018) propose a diagnostic algorithm using other methods for measuring blood pressure (Fig. 1).

Unresolved, from the point of view of ESH / ESC experts, remains the question of which of the methods for measuring blood pressure to use in patients with permanent form atrial fibrillation. There is also no evidence from large comparative studies that any method of out-of-office BP measurement has an advantage in predicting major CV events compared to in-office BP monitoring during therapy.

Assessment of cardiovascular risk and its reduction

The methodology for assessing the total CV risk has not changed and is more fully presented in the ESC Guidelines for the Prevention of Cardiovascular Diseases (2016) . It is proposed to use the European SCORE risk assessment scale for risk assessment in patients with 1st degree AH. However, it is indicated that the presence of risk factors that are not taken into account by the SCORE scale can significantly affect the total CV risk in a patient with hypertension.

New risk factors have been added, such as uric acid levels, early onset of menopause in women, psychosocial and socioeconomic factors, resting heart rate (HR) >80 bpm (Table 3).

Also, the assessment of CV risk in hypertensive patients is influenced by the presence of target organ damage (TOI) and diagnosed CV diseases, DM or kidney disease. No significant changes were made in relation to the detection of POM in patients with hypertension in the ESH / ESC (2018) recommendations.

As before, basic tests are offered: an electrocardiographic (ECG) study in 12 standard leads, determination of the ratio of albumin / creatinine in urine, calculation of the glomerular filtration rate by the level of plasma creatinine, fundoscopy and a series additional methods for more detailed detection of POM, in particular echocardiography to assess left ventricular hypertrophy (LVH), ultrasonography to assess the thickness of the intima-media complex carotid arteries and etc.

Be aware of the extremely low sensitivity of the ECG method for detecting LVH. So, when using the Sokolov-Lyon index, the sensitivity is only 11%. It means a large number of false-negative results in the detection of LVH, if with a negative ECG result studies do not perform echocardiography with the calculation of the myocardial mass index.

A classification of AH stages was proposed, taking into account the level of BP, the presence of POM, concomitant diseases, and total CV risk (Table 4).

This classification allows assessing the patient not only by the level of blood pressure, but primarily by his total CV risk.

It is emphasized that in patients with a moderate and higher level of risk, it is not enough to reduce blood pressure alone. Mandatory for them is the appointment of statins, which further reduce the risk of myocardial infarction by a third and the risk of stroke by a quarter with achieved control of blood pressure. It is also noted that a similar benefit was achieved with the use of statins in patients with lower risk. These recommendations significantly expand the indications for the use of statins in patients with hypertension.

In contrast, indications for the use of antiplatelet drugs (primarily low doses of acetylsalicylic acid) are limited to secondary prevention. Their use is recommended only for patients with diagnosed CV disease and is not recommended for hypertensive patients without CV disease, regardless of the total risk.

Initiation of therapy

Approaches to the initiation of therapy in patients with hypertension have undergone significant changes. The presence of a very high CV risk in a patient requires the immediate initiation of pharmacotherapy even with high normal blood pressure (Fig. 2).

The initiation of pharmacotherapy is also recommended for elderly patients over 65 years old, but not older than 90 years. However, the abolition of pharmacotherapy with antihypertensive drugs is not recommended after patients reach the age of 90 years, if they tolerate it well.

Target BP

Changing blood pressure targets has been actively discussed over the past 5 years and was actually initiated during the preparation of the US Joint Committee Recommendations on the Prevention, Diagnosis and Treatment of High Blood Pressure (JNC 8), which were published in 2014. The experts who prepared the JNC 8 Guidelines concluded that observational studies have shown an increase in cardiovascular risk already at SBP levels ≥115 mmHg. Art., and in -randomized -studies using antihypertensive drugs, only the benefit of reducing SBP to values ​​\u200b\u200b150 mm Hg was actually proven. Art. .

For solutions this issue initiated the SPRINT study, which randomized 9361 high-risk CV patients with SBP ≥130 mmHg. Art. without SD. The patients were divided into two groups, in one of which SBP was reduced to values<120 мм рт. ст. (интенсивная терапия), а во второй - ​<140 мм рт. ст. (стандартная терапия).

As a result, the number of major CV events was 25% less in the intensive care group. The results of the SPRINT study became the evidence base for the updated American recommendations published in 2017, which set target levels for reducing SBP<130 мм рт. ст. для всех больных АГ с установленным СС заболеванием или расчетным риском СС событий >10% in the next 10 years.

ESH / ESC experts emphasize that in the SPRINT study, blood pressure measurement was carried out according to a method that differs from traditional measurement methods, namely: the measurement was carried out at a clinic appointment, but the patient himself measured blood pressure with an automatic device.

With this method of measurement, the level of blood pressure is lower than with the "office" measurement of blood pressure by a doctor by approximately 5-15 mm Hg. Art., which should be taken into account when interpreting the data of the SPRINT study. In fact, the level of blood pressure achieved in the intensive care group in the SPRINT study corresponds approximately to a SBP level of 130-140 mm Hg. Art. with the "office" measurement of blood pressure at the doctor.

In addition, the authors of the ESH/ESC Guidelines for the Treatment of Hypertension (2018) cite a large qualitative meta-analysis showing significant benefit from a 10 mmHg reduction in SBP. Art. with initial SBP 130-139 mm Hg. Art. (Table 5).

Similar results were obtained in another meta-analysis, which, in addition, showed a significant benefit from lowering DBP.<80 мм рт. ст. .

Based on these studies, the ESH/ESC Guidelines for the Treatment of Hypertension (2018) set the target level of SBP reduction for all hypertensive patients.<140 мм рт. ст., что несколько отличает на первый взгляд новые европейские рекомендации от рекомендаций, принятых в 2017 году в США , которые определили для всех больных АГ целевой уровень САД <130 мм рт. ст.

However, further European experts propose an algorithm for achieving target levels of blood pressure, according to which, if the level of SBP is reached,<140 мм рт. ст. и хорошей переносимости терапии следует снизить уровень САД <130 мм рт. ст. (табл. 6). Таким образом, этот алгоритм фактически устанавливает целевой уровень САД <130 мм рт. ст., однако разбивает на два этапа процесс его достижения.

In addition, the target level of DBP is also set.<80 мм рт. ст. независимо от СС риска и сопутствующей патологии. Следует помнить, что чрезмерное снижение уровня ДАД (критическим является уровень ДАД <60 мм рт. ст.) приводит к увеличению риска СС катастроф, что подтвердилось также и в исследовании SPRINT, и необходимо его избегать. Рекомендации ESH/ESC по лечению АГ (2018) устанавливают также целевые уровни САД для отдельных категорий больных АГ (табл. 7).

The division of patients into groups introduces some clarifications into the target levels of SBP. Thus, in patients 65 years of age and older, it is recommended to achieve target levels of SBP from 130 to<140 мм рт. ст., а у больных до 65 лет рекомендуется более жесткий контроль АД и достижение целевого САД от 120 до <130 мм рт. ст.

Tight control is also recommended to achieve the target systolic blood pressure.<130 мм рт. ст. у больных с сопутствующим СД или ишемической болезнью сердца. Достижение целевого уровня САД от 120 до <130 мм рт. ст. также рекомендовано больным после перенесенного инсульта или транзиторной ишемической атаки, однако класс рекомендации более низкий, как и уровень доказательств.

In patients with CKD, less stringent BP control is recommended to achieve a target SBP of 130 to<140 мм рт. ст. Таким образом, для большинства больных АГ рекомендован целевой уровень САД <130 мм рт. ст. при офисном измерении АД за исключением пациентов от 65 лет и старше и больных с сопутствующей ХБП, что фактически максимально приближает новые Рекомендации ESH/ESC по лечению АГ (2018) к опубликованным в 2017 году американским рекомендациям .

Achieving BP control in patients remains a challenge. In most cases in Europe, blood pressure is controlled in less than 50% of patients. Given the new target levels of blood pressure, the ineffectiveness of monotherapy in most cases, and the decrease in patient adherence to treatment in proportion to the number of pills taken, the following algorithm for achieving blood pressure control was proposed (Fig. 3).

1. Hypertension can be diagnosed on the basis of not only "office", but also "out of office" measurement of blood pressure.
2. Initiation of pharmacotherapy at high normal BP in patients with very high CV risk, as well as in patients with grade 1 hypertension and low CV risk, if lifestyle changes do not lead to BP control. Start pharmacotherapy in elderly patients if they tolerate it well.
3. Setting a target level of SBP<130 мм рт. ст. у большинства больных, достигаемого в два этапа, после снижения САД <140 мм рт. ст. и хорошей переносимости терапии.
4. A new algorithm for achieving BP control in patients.

Literature

1. Williams, Mancia, et al. 2018 ESH/ESC Guidelines for the management of arterial hypertension. European Heart Journal. 2018, press.

2. Piepoli M. F., HoesA. W., AgewallS., AlbusC., BrotonsC., CatapanoA. L., CooneyM. T., CorraU., CosynsB., DeatonC., Graham I., HallM. S., HobbsF. D.R., Lochen M. L., LollgenH., Marques-Vidal P., PerkJ., PrescottE., RedonJ., RichterD. J., Sattar N., SmuldersY., TiberiM., van der WorpH. B., van DisI., VerschurenW. M.M., BinnoS. ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Heart Journal. 2016. Aug 1; 37 (29): 2315-2381.

3. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014; 311(5): 507-520.

4. The SPRINT Research Group. N.Engl. J.Med. 2015; 373:2103-2116.

5. Whelton P. K., CareyR. M., Aronow W. S., CaseyD. E.Jr., Collins K. J., Dennison HimmelfarbC., DePalma S.M., GiddingS., JamersonK. A ., JonesD. W., MacLaughlin E.J., Muntner P., OvbiageleB., SmithS. C.Jr., SpencerC. C., StaffordR. S., TalerS. J., ThomasR. J. , Williams K. A.Sr., Williamson J. D., Wright J. T.Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/ NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardio -logy/American Heart Association Task Force on Clinical Practice Guidelines. hypertension. Jun 2018; -
71-(6): e13-e115.

6. EttehadD., EmdinC. A., KiranA., AndersonS. G., CallenderT., EmbersonJ., ChalmersJ., RodgersA., RahimiK.Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016. Mar 5; 387 (10022): 957-967.

7. Thomopoulos C., Parati G., Zanchetti A. Effects of blood pressure lowering on outcome incidence in hyper-tension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels - ​updated overview and meta-analyses of randomized trials. J.Hypertens. 2016. Apr; 34(4): 613-22.

Thematic issue "Cardiology, Rheumatology, Cardiosurgery" No. 3 (58) cherven 2018

30.11.2019 Cardiology Neurology Management of patients with non-valvular atrial fibrillation after suffering intracranial hemorrhage: a tandem of a neurologist and a cardiologist

25-27 Spring in Kyiv, the XXNational Congress of Cardiologists of Ukraine is a large-scale forum, which traditionally calls for an active influx of both scientists and medical practitioners. For many years, the scientific program of the congress slandered a wide range of interdisciplinary clinical problems, and one of the most important was cardiocerebral damage. Zocrema, a lot of dopovidey was associated with the practical aspects of managing patients with non-valvular atrial fibrillation (NAF), as it is by far the most important risk factor for the development of cerebral stroke ....

29.11.2019 Cardiology A new look at the prevention of acetylsalicylic acid ingestion in patients with diabetes mellitus

The prevalence of cerebrodiabetes (CD) is steadily growing in the world in rich countries that are developing, already at 10% (Fras Z., 2019). Based on estimates, in 2017 in Europe, close to 60 million adults were ill with type 2 CD, and in half of them the disease was left undiagnosed (Cosentino F. et al., 2019). ...

Arterial hypertension is a leading risk factor for the development of cardiovascular, cerebrovascular and renal diseases. Arterial hypertension, clinical recommendations will be provided in this article

Arterial hypertension is a leading risk factor for the development of cardiovascular, cerebrovascular and renal diseases. Arterial hypertension, clinical recommendations - we will provide in this article.

Definition of arterial hypertension

Arterial hypertension is a syndrome of increased systolic blood pressure(SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg.

These blood pressure (BP) thresholds are based on the results of randomized controlled trials that have demonstrated the feasibility and benefit of treatment aimed at lowering these BP levels in patients with "hypertension" and "symptomatic arterial hypertension".

The term "hypertension" (AH), proposed by G.F. Lang in 1948 corresponds to the term "essential hypertension" (hypertension) used abroad.

Hypertension is commonly understood as a chronic disease in which an increase in blood pressure is not associated with the identification of obvious causes leading to the development of secondary forms. arterial hypertension(AG).

Hypertension prevails among all forms of arterial hypertension, its prevalence is over 90%. Due to the fact that GB is a disease that has various variants of the course in the literature, instead of the term "hypertension", the term " arterial hypertension(hypertension)".

Etiology and pathogenesis of hypertension

The pathogenesis of hypertension is not fully understood. The hemodynamic basis of an increase in blood pressure is an increase in the tone of arterioles due to hyperactivation of the sympathetic nervous system.

In the regulation of vascular tone, mediators of nervous excitation are currently of great importance, both in the central nervous system and in all links in the transmission of nerve impulses to the periphery, i.e., to the vessels.

Catecholamines (primarily norepinephrine) and serotonin are of primary importance. Their accumulation in the central nervous system is an important factor maintaining the state of increased excitation of the higher regulatory vascular centers, which is accompanied by an increase in the tone of the sympathetic nervous system. Impulses from the sympathetic centers are transmitted by complex mechanisms.

At least three paths are indicated:

1. along sympathetic nerve fibers.
2. By transmitting excitation along the preganglionic nerve fibers to the adrenal glands, followed by the release of catecholamines.
3. By excitation of the pituitary and hypothalamus, followed by the release of vasopressin into the blood.

Subsequently, in addition to the neurogenic mechanism, other mechanisms that increase blood pressure, in particular humoral ones, may additionally (successively) be included. Thus, in hypertension, two groups of factors can be distinguished:

• neurogenic, affecting through the sympathetic nervous system a direct effect on the tone of arterioles,
• humoral, associated with increased release of catecholamines and some other biologically active substances (renin, hormones of the adrenal cortex, etc.), which also cause a pressor effect.

When considering the pathogenesis of hypertension, it is also necessary to take into account the violation (weakening) of the mechanisms that have a depressant effect (depressor baroreceptors, the humoral depressor system of the kidneys, angiotensinase, etc.). Violation of the ratio of the activity of pressor and depressor systems leads to the development of arterial hypertension.

Epidemiology of arterial hypertension

Arterial hypertension (hypertension) is a leading risk factor for the development of cardiovascular (myocardial infarction, stroke, ischemic disease heart disease (CHD), chronic heart failure), cerebrovascular (ischemic or hemorrhagic stroke, transient ischemic attack) and kidney disease (chronic kidney disease).

Cardiovascular and cerebrovascular diseases, presented in official statistics as diseases of the circulatory system (CVD), are the leading causes of death in the Russian Federation; they account for more than 55% of deaths from the total number of deaths from all causes.

In modern society, there is a significant prevalence of hypertension, accounting for 30-45% among the adult population, according to foreign studies, and about 40%, according to Russian studies.

In the Russian population, the prevalence of hypertension among men is slightly higher, in some regions it reaches 47%, while among women the prevalence of hypertension is about 40%.

ICD 10 coding

• Diseases characterized by high blood pressure (I10-I15)
• I10 - Essential (primary) hypertension
• I11 - Hypertensive heart disease
• I12 - Hypertensive disease with a primary lesion of the kidneys
• I13 - Hypertensive disease with a primary lesion of the kidneys
• I15 - Secondary hypertension.

Secondary hypertension

Classification

The classification of blood pressure levels in people over 18 years of age is presented in Table 1.

Table 1 - Classification of blood pressure levels (mm Hg)

Note. * - ISAG should be classified into 1, 2, 3 tbsp. according to the level of systolic blood pressure.

If SBP and DBP values ​​fall into different categories, then the degree of hypertension is assessed in a higher category. The results of ambulatory blood pressure monitoring (ABPM) and blood pressure monitoring (SBP) may help in the diagnosis of hypertension, but do not replace repeated blood pressure measurements in a hospital (office or clinical blood pressure). Criteria for diagnosing hypertension based on the results of ABPM, SBP and blood pressure measurements made by a doctor are different. The data is presented in the table

2. Particular attention should be paid to the threshold values ​​of blood pressure at which hypertension is diagnosed during SCAD: SBP > 135 mm Hg. and/or DBP > 85 mmHg

Table 2 - Threshold levels of blood pressure (mm Hg) for the diagnosis of arterial hypertension according to various measurement methods

The criteria for elevated blood pressure are largely conditional, since there is a direct relationship between the level of blood pressure and the risk of cardiovascular disease (CVD). This connection begins with relatively low values ​​- 110-115 mm Hg. Art. for CAD and 7075 mmHg. Art. for DAD.

In persons over 50 years of age, SBP is a better predictor of cardiovascular complications (CVS) than DBP, while in younger patients, the opposite is true. In elderly and senile patients, increased pulse pressure (the difference between SBP and DBP) has additional prognostic value.

In persons with a high normal level of blood pressure at a doctor's appointment, it is advisable to conduct SCAD and / or ABPM to clarify the level of blood pressure (in conditions of daily activity), as well as dynamic monitoring of blood pressure.

Diagnostics

Diagnosis of hypertension and examination includes the following steps:

• clarification of complaints and collection of anamnesis;
• repeated measurements of blood pressure;
• physical examination;
• laboratory and instrumental research methods: simpler at the first stage and complex - at the second stage of the examination (according to indications).

Determination of the degree and stability of the increase in blood pressure is recommended by clinical (office) measurement of blood pressure (table 1) in patients with newly diagnosed increase in blood pressure.

History of arterial hypertension

Comments: history taking includes collection of information about the presence of risk factors, subclinical symptoms of POM, the presence of a history of CVD, CVD, CKD and secondary forms of hypertension, as well as previous experience in the treatment of hypertension.

Physical examination

Patients with hypertension are aimed at identifying risk factors, signs of secondary forms of hypertension and organ damage. Measure height, body weight with calculation of body mass index (BMI) in kg/m2 (determined by dividing body weight in kilograms by height in meters squared) and waist circumference, which is measured in a standing position (the patient should only wear underwear, the measurement point is the middle of the distance between the top of the iliac crest and the lower lateral edge of the ribs), the measuring tape should be held horizontally.

• general analysis of blood and urine;
• the study of glucose in blood plasma (on an empty stomach);
• study of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG);
• the study of potassium, sodium in the blood serum;

The method of self-monitoring of blood pressure - blood pressure indicators obtained during the SCAD, can be a valuable addition to clinical blood pressure in the diagnosis of hypertension and monitoring the effectiveness of treatment, but suggest the use of other standards (Table 2).

The value of BP obtained by the SCAD method correlates more closely with POM and disease prognosis than clinical BP, and its predictive value is comparable to the method of daily BP monitoring after adjusting for sex and age.

It has been proven that the SCAD method increases the adherence of patients to treatment. The limitations of using the SCAD method are those cases when the patient is inclined to use the obtained results for self-correction of therapy.

It must be taken into account that it cannot provide information about blood pressure levels during “everyday” (real) daytime activity, especially among the working part of the population, and at night. For ACS, traditional tonometers with dial gauges, as well as automatic and semi-automatic devices for home use that have passed certification, can be used.

To assess the level of blood pressure in situations of a sharp deterioration in the patient's well-being outside stationary conditions (on trips, at work, etc.), it is possible to recommend the use of automatic carpal blood pressure meters, but with the same rules for measuring blood pressure (2-3 times measurement, the location of the hand at the level of the heart etc.). It should be remembered that blood pressure measured at the wrist may be slightly lower than the blood pressure at the upper arm.

The method of daily monitoring of arterial pressure has a number of specific advantages:

Only the ABPM method allows you to determine the circadian rhythm of blood pressure, nocturnal hypotension or hypertension, blood pressure dynamics in the early morning hours, the uniformity and sufficiency of the antihypertensive effect of drugs.

Only devices that have successfully passed clinical trials according to international protocols, confirming the accuracy of measurements, can be recommended. When interpreting ABPM data, the focus should be on the average values ​​of blood pressure for the day, night and day; daily index (difference between blood pressure during the daytime and at night); the value of blood pressure in the morning; BP variability, daytime and nighttime (std) and pressure load indicator (percentage of elevated BP values ​​during daytime and nighttime hours).

Clinical indications for the use of ABPM and SCAD for diagnostic purposes:

1. Suspicion of white coat hypertension.
2. Patients with hypertension of the 1st degree according to clinical blood pressure.
3. High clinical BP in individuals without POM and in individuals with low overall cardiovascular risk.
4. Suspicion of "masked" hypertension.
5. High normal clinical blood pressure.
6. Normal clinical BP in individuals with POM and in individuals with a high overall cardiovascular risk.
7. Identification of "white coat hypertension" in patients with hypertension.
8. Significant fluctuations in clinical BP during the same or different visits to the doctor.
9. Vegetative, orthostatic, postprandial, drug hypotension; hypotension during daytime sleep.
10. Increased clinical blood pressure or suspicion of preeclampsia in pregnant women.
11. Identification of true and false refractory hypertension.

Specific indications for ABPM:

1. Pronounced discrepancies between the level of clinical blood pressure and data from the SCAD.
2. Assessment of the circadian rhythm of blood pressure.
3. Suspicion of nocturnal hypertension or absence of nocturnal BP reduction, e.g. in patients with sleep apnea, CKD, or diabetes.
4. Assessment of BP variability.

It is recommended to use CT or MRI in patients with hypertension to detect complications of hypertension (asymptomatic cerebral infarctions, lacunar infarctions, microhemorrhages and white matter lesions in dyscirculatory encephalopathy, transient ischemic attacks/strokes).

Assessment of the overall (total) cardiovascular risk

In asymptomatic hypertensive patients without CVD, CKD, and diabetes, risk stratification using the Systemic coronary risk evaluation (SCORE) model is recommended.

Comments: Detection of target organ damage is recommended because there is evidence that target organ damage is a predictor of CV mortality independent of SCORE.

Table 3 - Risk stratification in patients with arterial hypertension

Note. BP - arterial pressure, AG - arterial hypertension, CKD - ​​chronic kidney disease, DM - diabetes mellitus; DBP - diastolic blood pressure, SBP - systolic blood pressure.

Table 4 - Risk factors affecting prognosis used to stratify total cardiovascular risk

Formulation of the diagnosis

When formulating a diagnosis, the presence of RF, POM, CVD, CVD, CKD, cardiovascular risk should be reflected as fully as possible. The degree of increase in blood pressure must be indicated in patients with newly diagnosed hypertension. If the patient, then the degree of hypertension at the time of admission is indicated in the diagnosis. It is also necessary to indicate the stage of the disease.

According to the three-stage classification of GB, stage I GB implies the absence of POM, stage II GB - the presence of changes in one or more target organs. The diagnosis of stage GB is established in the presence of CVD, CVD, CKD.

Table 5 - Tactics of managing patients depending on the total cardiovascular risk

Treatment of arterial hypertension

Goals of therapy

The main goal of treating hypertensive patients is to maximum reduction the risk of developing complications of hypertension: fatal and non-fatal CVD, CVD and CKD.

To achieve this goal, it is necessary to reduce blood pressure to target levels, correct all modifiable risk factors (smoking, dyslipidemia, hyperglycemia, obesity, etc.), prevent/slow the rate of progression and/or reduce the severity (regression) of POM, as well as treat existing cardiovascular diseases. , cerebrovascular and renal diseases (table 5).

The most important aspect for a patient with hypertension is the decision on the advisability of prescribing antihypertensive therapy. Indications for the appointment of AGT are determined individually based on the value of the total (total) CVR (table 5).

Lifestyle interventions

Lifestyle interventions are recommended for all patients with hypertension. Non-drug methods of treating hypertension contribute to lowering blood pressure, reduce the need for antihistamines and increase their effectiveness, allow for the correction of risk factors, conduct primary prevention Hypertension in patients with high normal blood pressure and those with risk factors.

Comments: There is strong evidence for an association between salt intake and BP levels. Excessive salt intake may play a role in the development of refractory hypertension. Standard salt intake in many countries is from 9 to 12 g/day (80% of the salt consumed is the so-called "hidden salt"), reducing its intake to 5 g/day in hypertensive patients leads to a decrease in SBP by 4-5 mm Hg . Art.

The effect of sodium restriction is more pronounced in elderly and senile patients, in patients with DM, MS and CKD. Salt restriction can lead to a decrease in the number of antihistamines taken and their doses.

1. Patients are advised to reduce the consumption of alcoholic beverages.
2. Patients are advised to change their diet
3. Patients are advised to normalize body weight.
4. Patients are encouraged to increase physical activity.
5. Patients are advised to quit smoking.

Diagnosis and treatment of secondary forms of arterial hypertension (hypertension)

Secondary (symptomatic) hypertension - diseases in which the cause of increased blood pressure is damage to various organs or systems, and hypertension is only one of the symptoms of the disease. Secondary hypertension is detected in 5-25% of patients with hypertension. For the diagnosis of secondary forms of hypertension, a detailed examination of the patient is fundamentally important, starting with: laboratory diagnostics, to the execution of complex instrumental methods.

Surgery

When drug therapy fails, invasive procedures such as renal denervation and baroreceptor stimulation are recommended.

Hypertension or other arterial hypertension significantly increases the likelihood of stroke, heart attack, vascular disease and chronic kidney disease. Because of the morbidity, mortality, and costs to society, the prevention and treatment of hypertension is an important public health issue. Fortunately, recent advances and research in this area have led to an improved understanding of the pathophysiology of hypertension and the development of new pharmacological and interventional therapies for this common disease.

Development mechanisms

Why hypertension occurs is still unclear. The mechanism of its development has many factors and is very complex. It involves various chemical substances, vascular reactivity and tone, blood viscosity, the work of the heart and nervous system. A genetic predisposition to the development of hypertension is assumed. One of the modern hypotheses is the idea of ​​immune disorders in the body. immune cells impregnate target organs (vessels, kidneys) and cause persistent disruption of their work. This has been noted, in particular, in individuals with HIV infection and in patients who have taken immunosuppressants for a long time.

Initially, labile arterial hypertension is usually formed. It is accompanied by instability of pressure figures, increased work of the heart, and increased vascular tone. This is the first stage of the disease. At this time, diastolic hypertension is often recorded - an increase in only the lower pressure figure. This is especially common in young women who are overweight and associated with edema. vascular wall and increased peripheral resistance.

Subsequently, the increase in pressure becomes constant, the aorta, heart, kidneys, retina and brain are affected. The second stage of the disease begins. The third stage is characterized by the development of complications from the affected organs - myocardial infarction, renal failure, visual impairment, stroke and other serious conditions. Therefore, even labile arterial hypertension requires timely detection and treatment.

The progression of hypertension usually looks like this:

• transient arterial hypertension (temporary, only during stress or hormonal disruptions) in people 10–30 years old, accompanied by an increase in the release of blood by the heart;
• early, often labile arterial hypertension in persons under 40 years of age, who already have an increase in resistance to the blood flow of small vessels;
• disease with target organ damage in persons aged 30–50 years;
• accession of complications in the elderly; at this time, after a heart attack, the heart muscle weakens, the work of the heart and cardiac output decrease, and blood pressure often decreases - this condition is called "headless hypertension" and is a sign of heart failure.

The development of the disease is closely related to hormonal disorders in the body, primarily in the "renin - angiotensin - aldosterone" system, which is responsible for the amount of water in the body and vascular tone.

Causes of the disease

Essential hypertension, which accounts for up to 95% of cases of all hypertension, occurs under the influence of external adverse factors in combination with a genetic predisposition. However, specific genetic abnormalities responsible for the development of the disease have not been identified. Of course, there are exceptions when a violation in the work of one gene leads to the development of pathology - this is Liddle's syndrome, some types of pathology of the adrenal glands.

Secondary arterial hypertension can be a symptom of various diseases.

Renal causes account for up to 6% of all cases of hypertension and include damage to the tissue (parenchyma) and blood vessels of the kidneys. Renoparenchymal arterial hypertension can occur with such diseases:

• polycystic;
• chronic kidney disease;
• Liddle's syndrome;
• compression of the urinary tract by a stone or tumor;
• a tumor that secretes renin, a powerful vasoconstrictor.

Renovascular hypertension is associated with damage to the vessels that feed the kidneys:

• coarctation of the aorta;
• vasculitis;
• narrowing of the renal artery;
• collagenoses.

Endocrine arterial hypertension is less common - up to 2% of cases. They can be caused by certain medications, such as anabolic steroids, oral contraceptives, prednisolone, or non-steroidal anti-inflammatory drugs. Alcohol, cocaine, caffeine, nicotine and licorice root preparations also increase blood pressure.

An increase in pressure is accompanied by many diseases of the adrenal glands: pheochromocytoma, increased production of aldosterone, and others.

There is a group of hypertensions associated with brain tumors, poliomyelitis, or high intracranial pressure.

Finally, do not forget about these rarer causes of the disease:

• hyperthyroidism and hypothyroidism;
• hypercalcemia;
• hyperparathyroidism;
• acromegaly;
• obstructive sleep apnea syndrome;
• gestational hypertension.

Obstructive sleep apnea syndrome - common cause increased pressure. Clinically, it is manifested by periodic cessation of breathing during sleep due to snoring and the appearance of obstructions in the airways. Approximately half of these patients have high blood pressure. Treatment of this syndrome allows to normalize hemodynamic parameters and improve the prognosis in patients.

Definition and classification

Types of blood pressure - systolic (develops in the vessels at the time of systole, that is, contraction of the heart) and diastolic (preserved in the vascular bed due to its tone during myocardial relaxation).

The classification system has importance to decide on the aggressiveness of treatment or therapeutic interventions.

Arterial hypertension is an increase in pressure up to 140/90 mm Hg. Art. and higher. Often both of these figures increase, which is called systolic-diastolic hypertension.

Besides, blood pressure in hypertension may be normal in people on chronic antihypertensive medications. The diagnosis in this case is clear based on the history of the disease.

They speak of prehypertension at pressure levels up to 139/89 mm Hg. Art.

Degrees of arterial hypertension:

• first: up to 159/99 mm Hg. Art.;
• second: from 160 / from 100 mm Hg. Art.

Such a division is to a certain extent conditional, since the same patient under different conditions has different pressure indicators.

The classification given is based on an average of 2 or more values ​​obtained at each of 2 or more visits after the initial review by the physician. Unusually low readings should also be evaluated in terms of clinical significance, because they can not only worsen the patient's well-being, but also be a sign of serious pathology.

Classification of arterial hypertension: it can be primary, developed due to genetic reasons. Wherein true reason disease remains unknown. Secondary hypertension is caused by various diseases of other organs. Essential (without apparent reason) arterial hypertension is observed in 95% of all cases in adults and is called hypertension. In children, secondary hypertension predominates, which is one of the signs of some other disease.

Severe arterial hypertension, not amenable to treatment, is often associated precisely with an unrecognized secondary form, for example, with primary hyperaldosteronism. The uncontrolled form is diagnosed when the combination of three different antihypertensive medications, including a diuretic, does not bring the pressure to normal.

Clinical signs

Symptoms of arterial hypertension are often only objective, that is, the patient does not feel any complaints until he has damage to target organs. This is the insidiousness of the disease, because at the II-III stage, when the heart, kidneys, brain, fundus is already affected, it is almost impossible to reverse these processes.

What signs you need to pay attention to and consult a doctor, or at least start measuring pressure yourself with a tonometer and write it down in a self-control diary:

• dull pain in the left side of the chest;
• heart rhythm disturbances;
• neck pain;
• occasional dizziness and tinnitus;
• deterioration of vision, the appearance of spots, "flies" before the eyes;
• shortness of breath on exertion;
• cyanosis of the hands and feet;
• swelling or swelling of the legs;
• attacks of suffocation or hemoptysis.

An important part of the fight against hypertension is the timely full-fledged medical examination, which each person can undergo free of charge in their clinic. Health Centers also operate throughout the country, where doctors will talk about the disease and conduct its initial diagnosis.

Hypertensive crisis and its danger

In a hypertensive crisis, the pressure increases to 190/110 mm Hg. Art. and more. Such arterial hypertension can cause damage to internal organs and various complications:

• neurological: hypertensive encephalopathy, cerebral vascular accidents, cerebral infarction, subarachnoid hemorrhage, intracranial hemorrhage;
• cardiovascular: myocardial ischemia / heart attack, acute pulmonary edema, aortic dissection, unstable angina;
• others: sharp kidney failure, retinopathy with vision loss, eclampsia in pregnancy, microangiopathic hemolytic anemia.

A hypertensive crisis requires immediate medical attention.

Gestational hypertension is part of the so-called OPG-preeclampsia. If you do not seek help from a doctor, you may develop preeclampsia and eclampsia - conditions that life threatening mother and fetus.

Diagnosis

Diagnosis of arterial hypertension necessarily includes an accurate measurement of the patient's pressure, a targeted collection of anamnesis, a general examination and the receipt of laboratory and instrumental data, including a 12-channel electrocardiogram. These steps are necessary to determine the following provisions:

• damage to target organs (heart, brain, kidneys, eyes);
• probable causes of hypertension;
• baseline for further evaluation of the biochemical effects of therapy.

Based on a certain clinical picture or if secondary hypertension is suspected, other tests may be done - the level of uric acid in the blood, microalbuminuria (protein in the urine).

• echocardiography to determine the condition of the heart;
• ultrasound examination of internal organs to exclude damage to the kidneys and adrenal glands;
• tetrapolar rheography to determine the type of hemodynamics (treatment may depend on this);
• pressure monitoring on an outpatient basis to clarify fluctuations in the daytime and at night;
• daily monitoring of the electrocardiogram, combined with the definition of sleep apnea.

If necessary, an examination by a neurologist, ophthalmologist, endocrinologist, nephrologist and other specialists is scheduled, differential diagnosis secondary (symptomatic) hypertension.

Treatment of arterial hypertension as a first step involves the correction of lifestyle.

Lifestyle

Reducing pressure and risk to the heart is possible if at least 2 of the following rules are observed:

• weight loss (with a loss of 10 kg, the pressure decreases by 5–20 mm Hg);
• reducing alcohol consumption to 30 mg ethanol for men and 15 mg ethanol for normal weight women per day;
• salt intake no more than 6 grams per day;
• sufficient intake of potassium, calcium and magnesium with food;
• to give up smoking;
• reducing the intake of saturated fats (that is, solid, animal) and cholesterol;
• aerobic exercise for half an hour a day almost daily.

Medical treatment

If, despite all measures, arterial hypertension persists, there are various options drug therapy. In the absence of contraindications and only after consulting a physician, the first-line drug is usually a diuretic. It must be remembered that self-medication can cause irreversible negative consequences in patients with hypertension.

If there is a risk or an additional condition that has already developed, other components are included in the treatment regimen: ACE inhibitors (enalapril and others), calcium antagonists, beta-blockers, angiotensin receptor blockers, aldosterone antagonists in various combinations. The selection of therapy is carried out on an outpatient basis for a long time until the optimal combination for the patient is found. It will need to be used constantly.

Information for patients

Hypertension is a disease for life. It is impossible to get rid of it, with the exception of secondary hypertension. For optimal control of the disease, constant work on oneself and drug treatment. The patient must attend the "School for Patients with Arterial Hypertension", because adherence to treatment reduces cardiovascular risk and increases life expectancy.

What a patient with hypertension should know and do:

• maintain a normal weight and waist circumference;
• constantly engage in physical exercise;
• consume less salt, fat and cholesterol;
• consume more minerals, in particular, potassium, magnesium, calcium;
• limit the use of alcoholic beverages;
• quit smoking and the use of psychoactive substances.

Regular monitoring of blood pressure, visits to the doctor and behavioral correction will help a patient with hypertension maintain a high quality of life for many years.

-->

Features of hypertension grade 3

1. What is 3 degree hypertension
2. Risk groups of patients with hypertension
3. Symptoms
4. What to look out for
5. Causes of the development of hypertension of the 3rd degree

Hypertension is a fairly common problem. The most dangerous option is the 3rd degree this disease, however, when making a diagnosis, the stage and degree of risk are indicated.

People who have high blood pressure should understand what it threatens in order to take adequate measures in time and not increase the already high risk of complications. For example, if the diagnosis is hypertension risk 3, what is it, what do these numbers mean?

They mean that in a person with such a diagnosis, the risk of getting a complication due to hypertension is from 20 to 30%. If this indicator is exceeded, a diagnosis of grade 3 hypertension, risk 4, is made. Both diagnoses mean the need for urgent treatment measures.

What is 3 degree hypertension

This degree of the disease is considered severe. It is determined by blood pressure indicators, which look like this:

• Systolic pressure 180 mm Hg or more;
• Diastolic - 110 mm Hg and higher.

At the same time, the level of blood pressure is always elevated and is almost constantly kept at marks that are considered critical.

Risk groups of patients with hypertension

In total, it is customary to distinguish 4 such groups depending on the likelihood of damage to the heart, blood vessels and other target organs, as well as on the presence of aggravating factors:

• 1 risk - less than 15%, no aggravating factors;
• 2 risk - from 15 to 20%, aggravating factors no more than three;
• 3 risk - 20-30%, more than three aggravating factors;
• 4 risk - above 30%, more than three aggravating factors, there is damage to target organs.

Aggravating factors include smoking, lack of physical activity, overweight, chronic stress, poor nutrition, diabetes mellitus, endocrine disorders.

With grade 3 hypertension with a risk of 3, there is a threat to health. Many patients are in the 4th risk group. A high risk is also possible with lower blood pressure, since each organism is individual and has its own margin of safety.

In addition to the degree and risk group, the stage of hypertension is also determined:

• 1 - there are no changes and damages in target organs;
• 2 - changes in several target organs;
• 3 - except for target organ damage plus complications: heart attack, stroke.

Symptoms

With the development of hypertension up to degree 3 with risks 3 and 4, it is impossible not to notice the symptoms, because they appear quite clearly. The main symptom is critical levels of blood pressure, which causes all other manifestations of the disease.

Possible manifestations:

• Dizziness and headaches with throbbing;
• Flashing "flies" before the eyes;
• General deterioration of the condition;
• Weakness in arms and legs;
• Vision problems.

Why do these symptoms occur? The main problem with hypertension is damage to vascular tissue. High blood pressure increases the load on the vascular wall.

In response to this, the inner layer is damaged, and the muscular layer of the vessels increases, due to which their lumen narrows. For the same reason, the vessels become less elastic, cholesterol plaques form on their walls, the lumen of the vessels narrows even more, and blood circulation is even more difficult.

In general, the health risk is very high, and grade 3 hypertension with a risk of 3 threatens disability quite realistically. Target organs are especially affected:

• Heart;
• kidneys;
• Brain;
• Retina.

What's going on in the heart

The left ventricle of the heart expands, the muscle layer in its walls grows, and the elastic properties of the myocardium deteriorate. Over time, the left ventricle is not able to fully cope with its functions, which threatens the development of heart failure, if timely adequate measures are not taken.

Kidney damage

The kidneys are an organ that is richly supplied with blood, so they often suffer from high blood pressure. Damage to the renal vessels impairs their blood supply.

The result is chronic renal failure, since the destructive processes in the vessels lead to changes in the tissues, for this reason, the functions of the organ are disrupted. Kidney damage is possible with stage 2 hypertension, grade 3 risk 3.

With hypertension, the brain also suffers from impaired blood supply. This is due to sclerosis and a decrease in the tone of the vessels, the brain itself, as well as the arteries that run along the spine.

The situation is aggravated if the patient's vessels are strongly tortuous, which often happens in this part of the body, since the tortuosity contributes to the formation of blood clots. As a result, in hypertension without timely adequate assistance, the brain receives less nutrition and oxygen.

The patient's memory deteriorates, attention decreases. Perhaps the development of encephalopathy, accompanied by a decrease in intelligence. These are very unpleasant consequences, as they can lead to loss of performance.

The formation of blood clots in the vessels supplying the brain increases the likelihood of an ischemic stroke, and the separation of a blood clot can lead to a hemorrhagic stroke. The consequences of such conditions can be catastrophic for the body.

Impact on the organs of vision

In some patients with grade 3 hypertension with grade 3 risk, retinal vessels are damaged. This negatively affects visual acuity, it decreases, and flickering of “flies” before the eyes is also possible. Sometimes a person feels pressure on eyeballs, in this state, he constantly feels drowsiness, performance decreases.

Another risk is hemorrhage.

One of the formidable complications of grade 3 hypertension with a risk of 3 is hemorrhage in various organs. This happens for two reasons.

1. First, the thickening walls of blood vessels lose their elasticity so much that they become brittle.
2. Secondly, hemorrhages are possible at the site of the aneurysm, because here the walls of the vessels from overflow become thinner and easily torn.

Small bleeding as a result of a rupture of a vessel or aneurysm leads to the formation of hematomas, in the case of large ruptures, hematomas can be massive and damage internal organs. Severe bleeding is also possible, which requires urgent medical attention to stop.

There is an opinion that a person immediately feels increased pressure, but this does not always happen. Everyone has their own sensitivity threshold.

The most common variant of the development of hypertension is the absence of symptoms until the onset of a hypertensive crisis. This already means the presence of hypertension of the 2nd degree of the 3rd stage, since given state indicates organ damage.

The period of asymptomatic course of the disease can be quite long. If a hypertensive crisis does not occur, then the first symptoms gradually appear, to which the patient often does not pay attention, attributing everything to fatigue or stress. Such a period can last even until the development of arterial hypertension of the 2nd degree with a risk of 3.

What to look out for

• Regular dizziness and headaches;
• Feeling of tightness in the temples and heaviness in the head;
• Noise in ears;
• "Flies" before the eyes;
• General decrease in tone4
• Sleep disorders.

If you do not pay attention to these symptoms, then the process goes on, and the increased load on the vessels gradually damages them, they do their job worse and worse, the risks grow. The disease passes into the next stage and the next degree. Arterial hypertension grade 3 risk 3 can progress very quickly.

As a result, more serious symptoms appear:

• Irritability;
• Decreased memory;
• Shortness of breath with little physical exertion;
• visual disturbances;
• Interruptions in the work of the heart.

With grade 3 hypertension, risk 3 is more likely to cause disability due to extensive vascular damage.

Causes of the development of hypertension of the 3rd degree

The main reason for the development of such a serious condition as grade 3 hypertension is the lack of treatment or insufficient therapy. This can happen, both through the fault of the doctor and the patient himself.

If the doctor is inexperienced or inattentive and has developed an inappropriate treatment regimen, then it will not be possible to lower blood pressure and stop the destructive processes. The same problem awaits patients who are inattentive to themselves and do not follow the instructions of a specialist.

For a correct diagnosis, an anamnesis is very important, that is, information obtained during examination, acquaintance with the documents and from the patient himself. Complaints, blood pressure indicators, the presence of complications are taken into account. Blood pressure should be measured regularly.

To make a diagnosis, the doctor needs data for dynamic observation. To do this, you need to measure this indicator twice a day for two weeks. Blood pressure measurement data allow you to assess the state of blood vessels.

Other diagnostic measures

• Listening to lungs and heart sounds;
• Percussion of the vascular bundle;
• Determining the configuration of the heart;
• Electrocardiogram;
• Ultrasound of the heart, kidneys and other organs.

To clarify the state of the body, it is necessary to do tests:

• The content of glucose in blood plasma;
• General analysis of blood and urine;
• The level of creatinine, uric acid, potassium;
• Determination of creatinine clearance.

In addition, the doctor may prescribe additional examinations necessary for a particular patient. In patients with stage 3 hypertension, grade 3 risk 3, there are additional aggravating factors that require even more careful attention.

Treatment of hypertension stage 3 risk 3 implies a set of measures that includes drug therapy, diet and active lifestyle. It is mandatory to refuse bad habits- smoking and drinking alcohol. These factors significantly aggravate the condition of the vessels and increase the risks.

For the treatment of hypertension with risks 3 and 4, drug treatment with one drug will not be enough. A combination of drugs from different groups is required.

To ensure the stability of blood pressure indicators, mainly prolonged drugs are prescribed, which last up to 24 hours. The selection of drugs for the treatment of grade 3 hypertension is carried out based not only on blood pressure indicators, but also on the presence of complications and other diseases. Prescribed drugs should not have side effects undesirable for a particular patient.

The main groups of drugs

• Diuretic;
• ACE inhibitors;
• β-blockers;
• calcium channel blockers;
• AT2 receptor blockers.

In addition to drug therapy, it is necessary to adhere to a diet, work and rest, to give yourself feasible loads. The results of treatment may not be noticeable immediately after it has begun. It takes a long time for the symptoms to start to improve.

Appropriate nutrition in hypertension is an important part of treatment.

You will have to exclude products that contribute to the rise in pressure and the accumulation of cholesterol in the vessels.

Salt intake should be kept to a minimum, ideally no more than half a teaspoon per day.

Prohibited Products

• Smoked products;
• pickles;
• Spicy dishes;
• Coffee;
• Semi-finished products;
• Strong tea.

It is impossible to completely cure arterial hypertension of grade 3, risk 3, but it is really possible to stop the destructive processes and help the body recover. The life expectancy of patients with grade 3 hypertension depends on the degree of development of the disease, the timeliness and quality of treatment, and the patient's compliance with the recommendations of the attending physician.

The material was prepared by Villevalde S.V., Kotovskaya Yu.V., Orlova Ya.A.

The highlight of the 28th European Congress on Hypertension and Cardiovascular Prevention was the first presentation new version joint recommendations for the management of arterial hypertension (AH) of the European Society of Cardiology and the European Society for Hypertension. The text of the document will be published on August 25, 2018 simultaneously with official presentation at the Congress of the European Society of Cardiology, which will be held August 25-29, 2018 in Munich. The publication of the full text of the document will undoubtedly give rise to analysis and detailed comparison with the recommendations of the American societies, presented in November 2017 and radically changing the diagnostic criteria for hypertension and target levels of blood pressure (BP). The purpose of this material is to provide information on the key provisions of the updated European recommendations.

You can watch the full recording of the plenary meeting, where the recommendations were presented, on the website of the European Society for Hypertension www.eshonline.org/esh-annual-meeting.

Classification of blood pressure levels and definition of hypertension

The experts of the European Society for Hypertension retained the classification of blood pressure levels and the definition of hypertension and recommend classifying blood pressure as optimal, normal, high normal, and distinguishing degrees 1, 2 and 3 of hypertension (recommendation class I, level of evidence C) (Table 1).

Table 1 Classification of clinical BP

The criterion for hypertension according to the clinical measurement of blood pressure remained the level of 140 mm Hg. and above for systolic (SBP) and 90 mm Hg. and above - for diastolic (DBP). For home measurement of blood pressure, SBP of 135 mm Hg was retained as a criterion for hypertension. and above and / or DBP 85 mm Hg. and higher. According to the data of 24-hour blood pressure monitoring, the diagnostic cut-off points were 130 and 80 mm Hg for the average daily blood pressure, respectively, daytime - 135 and 85 mm Hg, night - 120 and 70 mm Hg (Table 2) .

Table 2. Diagnostic criteria Hypertension according to clinical and ambulatory measurements

BP measurement

The diagnosis of hypertension continues to be based on clinical BP measurements, with the use of ambulatory BP measurements being encouraged and the complementary value of 24-hour monitoring (ABPM) and home BP measurement being emphasized. With regard to office BP measurement without the presence of medical personnel, it is recognized that there are currently insufficient data to recommend it for widespread clinical use.

Advantages of ABPM include: detection of white-coat hypertension, stronger predictive value, assessment of BP levels at night, measurement of BP in the patient's real life setting, additional ability to identify predictive BP phenotypes, broad information in a single study, including short-term BP variability. The limitations of ABPM include the high cost and limited availability of the study, as well as its possible inconvenience for the patient.

Benefits of home BP measurement include detection of white-coat hypertension, cost-effectiveness and wide availability, BP measurement in familiar settings where the patient is more relaxed than at the doctor's office, patient participation in BP measurement, reusability over long periods of time, and assessment of variability "day by day". The disadvantage of the method is the possibility of obtaining measurements only at rest, the probability of erroneous measurements and the absence of measurements during sleep.

The following are recommended indications for ambulatory BP measurement (ABPM or home BP): conditions where there is a high likelihood of white coat hypertension (grade 1 hypertension on clinical measurement, significant elevation in clinical BP without target organ damage associated with hypertension), conditions when occult hypertension is highly likely (high clinically measured normal BP, normal clinical BP in a patient with end organ damage or high overall cardiovascular risk), postural and postprandial hypotension in patients not receiving and receiving antihypertensive therapy, evaluation of resistant hypertension , assessment of BP control, especially in high-risk patients, excessive BP response to physical activity, significant variability in clinical blood pressure, assessment of symptoms indicating hypotension during antihypertensive therapy. A specific indication for ABPM is assessment of nocturnal BP and nocturnal BP reduction (eg, in suspected nocturnal hypertension in patients with sleep apnea, chronic kidney disease (CKD), diabetes mellitus (DM), endocrine hypertension, autonomic dysfunction).

Screening and diagnosis of hypertension

For the diagnosis of hypertension, clinical measurement of blood pressure is recommended as the first step. When hypertension is detected, it is recommended to either measure BP at follow-up visits (except in cases of grade 3 BP elevation, especially in high-risk patients) or perform ambulatory BP measurement (ABPM or BP self-monitoring (SBP)). At each visit, 3 measurements should be performed with an interval of 1-2 minutes, an additional measurement should be performed if the difference between the first two measurements is more than 10 mmHg. For the level of blood pressure of the patient take the average of the last two measurements (IC). Ambulatory BP measurement is recommended in a number of clinical settings such as detection of white coat or occult hypertension, quantification of treatment efficacy, and detection of adverse events (symptomatic hypotension) (IA).

If white-coat hypertension or occult hypertension is identified, lifestyle interventions to reduce cardiovascular risk are recommended, as well as regular follow-up with ambulatory blood pressure (IC) measurements. In patients with white coat hypertension, medical treatment of hypertension may be considered in the presence of hypertension-related target organ damage or high/very high CV risk (IIbC), but routine BP-lowering drugs are not indicated (IIIC) .

In patients with latent hypertension, pharmacological antihypertensive therapy should be considered to normalize ambulatory BP (IIaC), and in treated patients with uncontrolled ambulatory BP, intensification of antihypertensive therapy should be considered due to the high risk of cardiovascular complications (IIaC).

Regarding the measurement of blood pressure, the question of the optimal method for measuring blood pressure in patients with atrial fibrillation remains unresolved.

Figure 1. Algorithm for screening and diagnosing hypertension.

Classification of hypertension and stratification by the risk of developing cardiovascular complications

The Guidelines retain the SCORE approach to overall cardiovascular risk, recognizing that in patients with hypertension, this risk is significantly increased in the presence of target organ damage associated with hypertension (especially left ventricular hypertrophy, CKD). Among the factors influencing the cardiovascular prognosis in patients with hypertension, the level of uric acid was added (more precisely, returned), the level of uric acid was added, early menopause, psychosocial and economic factors were added, heart rate at rest was 80 bpm or more. Asymptomatic target organ damage associated with hypertension is classified as moderate CKD with glomerular filtration rate (GFR)<60 мл/мин/1,73м 2 , и тяжелая ХБП с СКФ <30 мл/мин/1,73 м 2 (расчет по формуле CKD-EPI), а также выраженная ретинопатия с геморрагиями или экссудатами, отеком соска зрительного нерва. Бессимптомное поражение почек также определяется по наличию микроальбуминурии или повышенному отношению альбумин/креатинин в моче.

The list of established diseases of the cardiovascular system is supplemented by the presence of atherosclerotic plaques in imaging studies and atrial fibrillation.

An approach has been introduced to the classification of hypertension by disease stages (hypertension), taking into account the level of blood pressure, the presence of risk factors affecting the prognosis, target organ damage associated with hypertension, and comorbid conditions (Table 3).

The classification covers the range of blood pressure from high normal to grade 3 hypertension.

There are 3 stages of AH (hypertension). The stage of hypertension does not depend on the level of blood pressure, it is determined by the presence and severity of target organ damage.

Stage 1 (uncomplicated) - there may be other risk factors, but there is no target organ damage. At this stage, patients with grade 3 hypertension, regardless of the number of risk factors, as well as patients with grade 2 hypertension with 3 or more risk factors, are classified as high-risk at this stage. The moderate-high risk category includes patients with grade 2 hypertension and 1-2 risk factors, as well as grade 1 hypertension with 3 or more risk factors. The category of moderate risk includes patients with grade 1 hypertension and 1-2 risk factors, grade 2 hypertension without risk factors. Patients with high normal BP and 3 or more risk factors are at low-moderate risk. The rest of the patients were classified as low risk.

Stage 2 (asymptomatic) implies the presence of asymptomatic target organ damage associated with hypertension; CKD stage 3; Diabetes without target organ damage and implies the absence of symptomatic cardiovascular disease. The state of the target organs corresponding to stage 2, with high normal blood pressure, classifies the patient as a moderate-high risk group, with an increase in blood pressure of 1-2 degrees - as a high-risk category, 3 degrees - as a high-very high risk category.

Stage 3 (complicated) is determined by the presence of symptomatic cardiovascular diseases, CKD stage 4 and above, diabetes with target organ damage. This stage, regardless of the level of blood pressure, puts the patient in the category of very high risk.

Assessment of organ lesions is recommended not only to determine the risk, but also for monitoring during treatment. A change in electrocardiographic and echocardiographic signs of left ventricular hypertrophy, GFR during treatment has a high prognostic value; moderate - dynamics of albuminuria and ankle-brachial index. The change in the thickness of the intima-medial layer of the carotid arteries has no prognostic value. There is not enough data to conclude on the prognostic value of the pulse wave velocity dynamics. There are no data on the significance of the dynamics of signs of left ventricular hypertrophy according to magnetic resonance imaging.

The role of statins is emphasized in reducing CV risk, including greater risk reduction while achieving BP control. Antiplatelet therapy is indicated for secondary prevention and is not recommended for primary prevention in patients without cardiovascular disease.

Table 3. Classification of hypertension by stages of the disease, taking into account the level of blood pressure, the presence of risk factors affecting the prognosis, damage to target organs, associated with hypertension and comorbid conditions

POM - target organ damage, AH-POM - target organ damage associated with hypertension, RF - risk factors, CVD - cardiovascular diseases, DM - diabetes mellitus, CKD - ​​chronic kidney disease

Initiation of antihypertensive therapy

All patients with hypertension or high normal BP are recommended to make lifestyle changes. The timing of initiation of drug therapy (simultaneously with non-drug interventions or delayed) is determined by the level of clinical BP, the level of cardiovascular risk, the presence of target organ damage or cardiovascular disease (Fig. 2). As before, the immediate initiation of drug antihypertensive therapy is recommended for all patients with grade 2 and 3 hypertension, regardless of the level of cardiovascular risk (IA), while the target level of blood pressure should be achieved no later than 3 months.

In patients with grade 1 hypertension, recommendations for lifestyle changes should begin with evaluation of their effectiveness in normalizing blood pressure (IIB). In patients with grade 1 hypertension at high/very high CV risk, with CV disease, kidney disease, or evidence of end organ damage, antihypertensive drug therapy is recommended concomitantly with initiation of lifestyle interventions (IA). A more decisive (IA) approach compared to the 2013 Guidelines (IIaB) is the approach to initiating antihypertensive drug therapy in patients with grade 1 hypertension at low-moderate CV risk without heart or kidney disease, without evidence of target organ damage and not normalized BP at 3-6 months of initial lifestyle change strategy.

New in the 2018 Guidelines is the possibility of drug therapy in patients with high normal blood pressure (130-139/85-89 mm Hg) in the presence of a very high cardiovascular risk due to the presence of cardiovascular diseases, especially coronary heart disease (CHD). ) (IIbA). According to the 2013 Guidelines, antihypertensive drug therapy was not indicated in patients with high normal BP (IIIA).

One of the new conceptual approaches in the 2018 version of the European guidelines is a less conservative approach to BP control in the elderly. Experts suggest lower cut-off BP levels for initiation of antihypertensive therapy and lower target BP levels in elderly patients, emphasizing the importance of assessing the biological rather than chronological age of the patient, taking into account senile asthenia, self-care ability, and tolerability of therapy.

In fit older patients (even those >80 years of age), antihypertensive therapy and lifestyle changes are recommended when SBP is ≥160 mmHg. (IA). Upgraded recommendation grade and level of evidence (to IA vs. IIbC in 2013) for antihypertensive drug therapy and lifestyle changes in fit older patients (> 65 years but not older than 80 years) with SBP in the range of 140-159 mm Hg, subject to good tolerability of treatment. If therapy is well tolerated, drug therapy may also be considered in frail elderly patients (IIbB).

It should be borne in mind that reaching a certain age by a patient (even 80 years or more) is not a reason for not prescribing or canceling antihypertensive therapy (IIIA), provided that it is well tolerated.

Figure 2. Initiation of lifestyle changes and antihypertensive drug therapy in various levels clinical BP.

Notes: CVD = cardiovascular disease, CAD = coronary artery disease, AH-POM = target organ damage associated with hypertension

Target BP levels

Presenting their attitude to the results of the SPRINT study, which were taken into account in the United States when formulating new criteria for diagnosing hypertension and target levels of blood pressure, European experts point out that office measurement of blood pressure without the presence of medical staff has not previously been used in any of the randomized clinical research, which served as an evidence base for making decisions on the treatment of hypertension. When measuring blood pressure without the presence of medical staff, there is no white coat effect, and compared to the usual measurement, the level of SBP can be lower by 5-15 mmHg. It is hypothesized that SBP levels in the SPRINT study may correspond to SBP levels commonly measured at 130-140 and 140-150 mmHg. in groups of more and less intensive antihypertensive therapy.

Experts acknowledge that there is strong evidence of benefit from lowering SBP below 140 and even 130 mmHg. The data of a large meta-analysis of randomized clinical trials (Ettehad D, et al. Lancet. 2016;387(10022):957-967), which showed a significant reduction in the risk of developing major hypertension-associated cardiovascular complications with a decrease in SBP for every 10 mm, are presented. Hg at an initial level of 130-139 mm Hg. (i.e., when the SBP level is less than 130 mm Hg on treatment): the risk of coronary artery disease by 12%, stroke - by 27%, heart failure - by 25%, major cardiovascular events - by 13%, death from any reasons - by 11%. In addition, another meta-analysis of randomized trials (Thomopoulos C, et al, J Hypertens. 2016;34(4):613-22) also demonstrated a reduction in the risk of major cardiovascular outcomes when SBP was less than 130 or DBP was less than 80 mmHg compared with a less intense decrease in blood pressure (mean blood pressure levels were 122.1/72.5 and 135.0/75.6 mm Hg).

However, European experts also provide arguments in support of a conservative approach to target BP levels:

• the incremental benefit of lowering BP decreases as BP targets decrease;
• achieving more low levels BP on antihypertensive therapy is associated with a higher incidence of serious adverse events and discontinuation of therapy;
• less than 50% of patients on antihypertensive therapy currently achieve target SBP levels<140 мм рт.ст.;
• Evidence for the benefit of lower BP targets is less strong in several important subpopulations of patients with hypertension: the elderly, those with diabetes, CKD, and coronary artery disease.

As a result, the European recommendations of 2018 designate as the primary goal the achievement of a target level of blood pressure less than 140/90 mmHg. in all patients (IA). Subject to good tolerability of therapy, it is recommended to reduce blood pressure to 130/80 mm Hg. or lower in most patients (IA). As the target level of DBP, a level below 80 mm Hg should be considered. in all patients with hypertension, regardless of the level of risk or comorbid conditions (IIaB).

However, the same BP level cannot be applied to all hypertensive patients. Differences in target levels of SBP are determined by the age of patients and comorbid conditions. Lower SBP targets of 130 mmHg are suggested. or lower for patients with diabetes (subject to careful monitoring of adverse events) and coronary artery disease (Table 4). In patients with a history of stroke, a target SBP of 120 should be considered (<130) мм рт.ст. Пациентам с АГ 65 лет и старше или имеющим ХБП рекомендуется достижение целевого уровня САД 130 (<140) мм рт.ст.

Table 4. Target levels of SBP in selected subpopulations of patients with hypertension

Notes: DM, diabetes mellitus; CAD, coronary heart disease; CKD, chronic kidney disease; TIA, transient ischemic attack; * - careful monitoring of adverse events; **- if transferred.

The summarizing position of the 2018 Recommendations on target ranges for office blood pressure is presented in Table 5. A new provision that is important for real clinical practice is the designation of the level below which blood pressure should not be reduced: for all patients it is 120 and 70 mmHg.

Table 5 Target ranges for clinical BP

Notes: DM = diabetes mellitus, CAD = coronary heart disease, CKD = chronic kidney disease, TIA = transient ischemic attack.

When discussing ambulatory BP targets (ABPM or BPDS), it should be kept in mind that no randomized clinical trial with hard endpoints has used ABPM or systolic blood pressure as criteria for changing antihypertensive therapy. Data on target levels of ambulatory blood pressure are obtained only by extrapolation of the results of observational studies. In addition, differences between office and ambulatory BP levels decrease as office BP decreases. Thus, the convergence of 24-hour and office blood pressure is observed at a level of 115-120/70 mm Hg. It can be considered that the target level of office SBP is 130 mm Hg. approximately corresponds to a 24-hour SBP level of 125 mmHg. with ABPM and SBP<130 мм рт.ст. при СКАД.

Along with the optimal target levels of ambulatory blood pressure (ABPM and SBP), questions remain about the target levels of blood pressure in young patients with hypertension and low cardiovascular risk, the target level of DBP.

Lifestyle changes

Treatment for hypertension includes lifestyle changes and drug therapy. Many patients will require drug therapy, but image changes are essential. They can prevent or delay the development of hypertension and reduce cardiovascular risk, delay or eliminate the need for drug therapy in patients with grade 1 hypertension, and enhance the effects of antihypertensive therapy. However, lifestyle changes should never be a reason to delay drug therapy in patients at high CV risk. The main disadvantage of non-pharmacological interventions is the low adherence of patients to their compliance and its decline over time.

Recommended lifestyle changes with proven BP-lowering effects include salt restriction, no more than moderate alcohol consumption, high fruit and vegetable intake, weight loss and maintenance, and regular exercise. In addition, a strong recommendation to stop smoking is mandatory. Tobacco smoking has an acute pressor effect that can increase ambulatory daytime BP. Smoking cessation, in addition to the effect on blood pressure, is also important for reducing cardiovascular risk and preventing cancer.

In the previous version of the guidelines, the levels of evidence for lifestyle interventions were categorized in terms of effects on BP and other cardiovascular risk factors and hard endpoints (CV outcomes). In the 2018 Guidelines, the experts indicated the pooled level of evidence. The following lifestyle changes are recommended for patients with hypertension:

• Limit salt intake to 5 g per day (IA). A tougher stance compared to the 2013 version, where a limit of up to 5-6 g per day was recommended;
• Limiting alcohol consumption to 14 units per week for men, up to 7 units per week for women (1 unit - 125 ml of wine or 250 ml of beer) (IA). In the 2013 version, alcohol consumption was calculated in terms of grams of ethanol per day;
• Heavy drinking should be avoided (IIIA). New position;
• Increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil); consumption of low-fat dairy products; low consumption of red meat (IA). The experts emphasized the need to increase the consumption of olive oil;
• Control body weight, avoid obesity (body mass index (BMI) >30 kg/m2 or waist circumference over 102 cm in men and over 88 cm in women), maintain a healthy BMI (20-25 kg/m2) and waist circumference (less than 94 cm in men and less than 80 cm in women) to reduce blood pressure and cardiovascular risk (IA);
• Regular aerobic exercise (at least 30 minutes of moderate dynamic physical activity 5 to 7 days a week) (IA);
• Smoking cessation, support and assistance measures, referral to smoking cessation programs (IB).

Unresolved questions remain about the optimal level of salt intake to reduce cardiovascular risk and the risk of death, the effects of other non-drug interventions on cardiovascular outcomes.

Drug treatment strategy for hypertension

In the new Recommendations, 5 classes of drugs are retained as basic antihypertensive therapy: ACE inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), beta-blockers (BB), calcium antagonists (CA), diuretics (thiazide and tazido-like (TD), such as chlorthalidone or indapamide) (IA). At the same time, some changes in the position of the BB are indicated. They can be prescribed as antihypertensive drugs in the presence of specific clinical situations, such as heart failure, angina pectoris, myocardial infarction, the need for rhythm control, pregnancy or its planning. Bradycardia (heart rate less than 60 bpm) was included as absolute contraindications to BB, and chronic obstructive pulmonary disease was excluded as a relative contraindication to their use (Table 6).

Table 6. Absolute and relative contraindications to the prescription of the main antihypertensive drugs.

Notes: LV EF - left ventricular ejection fraction, FC - functional class. * - Changes in bold type compared to 2013 recommendations.

The experts placed particular emphasis on starting therapy with 2 drugs for most patients. The main argument for using combination therapy as an initial strategy is the reasonable concern that when prescribing one drug with the prospect of further dose titration or the addition of a second drug at subsequent visits, most patients will remain on insufficiently effective monotherapy for a long period of time.

Monotherapy is considered acceptable as a starting point for low-risk patients with grade 1 hypertension (if SBP<150 мм рт.ст.) и очень пожилых пациентов (старше 80 лет), а также у пациенто со старческой астенией, независимо от хронологического возраста (табл. 7).

One of the most important components of successful BP control is patient adherence to treatment. In this regard, combinations of two or more antihypertensive drugs combined in one tablet are superior to free combinations. In the new 2018 Guidelines, the class and level of evidence for initiation of therapy from a double fixed combination (the “one pill” strategy) has been upgraded to IB.

Recommended combinations remain combinations of RAAS blockers (ACE inhibitors or ARBs) with AKs or TDs, preferably in "one pill" (IA). It is noted that other drugs from the 5 main classes can be used in combinations. If dual therapy fails, a third antihypertensive drug should be prescribed. As a base, the triple combination of RAAS blockers (ACE inhibitors or ARBs), AK with TD (IA) retains its priorities. If the target blood pressure levels are not achieved on triple therapy, the addition of small doses of spironolactone is recommended. If it is intolerant, eplerenone or amiloride or high-dose TD or loop diuretics may be used. Beta or alpha blockers may also be added to therapy.

Table 7. Algorithm for medical treatment of uncomplicated hypertension (can also be used for patients with target organ damage, cerebrovascular disease, diabetes mellitus and peripheral atherosclerosis)

The Guidelines present approaches to the management of AH patients with comorbid conditions. When combining hypertension with CKD, as in the previous Recommendations, it is indicated that it is mandatory to replace TD with loop diuretics when GFR decreases below 30 ml/min/1.73 m2 (Table 8), as well as the impossibility of prescribing two RAAS blockers (IIIA). The issue of "individualization" of therapy depending on the tolerability of treatment, indicators of kidney function and electrolytes (IIaC) is discussed.

Table 8. Algorithm for drug treatment of hypertension in combination with CKD

The algorithm of drug treatment of hypertension in combination with coronary heart disease (CHD) has more significant features (Table 9). In patients with a history of myocardial infarction, it is recommended to include BB and RAAS blockers (IA) in the composition of therapy; in the presence of angina, preference should be given to BB and / or AC (IA).

Table 9. Algorithm for drug treatment of hypertension in combination with coronary artery disease.

An obvious choice of drugs has been proposed for patients with chronic heart failure (CHF). In patients with CHF and low EF, the use of ACE inhibitors or ARBs and beta-blockers is recommended, as well as, if necessary, diuretics and / or mineralocorticoid receptor (IA) antagonists. If the target blood pressure is not achieved, the possibility of adding dihydropyridine AK (IIbC) is suggested. Because no single drug group has been shown to be superior in patients with preserved EF, all 5 classes of antihypertensive agents (ICs) can be used. In patients with left ventricular hypertrophy, it is recommended to prescribe RAAS blockers in combination with AK and TD (I A).

Long-term follow-up of patients with hypertension

The decrease in blood pressure develops after 1-2 weeks from the start of therapy and continues for the next 2 months. During this period, it is important to schedule the first visit to assess the effectiveness of treatment and monitor the development of side effects of drugs. Subsequent monitoring of blood pressure should be carried out at the 3rd and 6th months of therapy. The dynamics of risk factors and the severity of target organ damage should be assessed after 2 years.

Particular attention is paid to the observation of patients with high normal blood pressure and white-coat hypertension, for whom it was decided not to prescribe drug therapy. They should be reviewed annually to assess BP, changes in risk factors, and lifestyle changes.

At all stages of patient monitoring, adherence to treatment should be assessed as a key reason for poor BP control. To this end, it is proposed to carry out activities at several levels:

• Physician level (providing information about the risks associated with hypertension and the benefits of therapy; prescribing optimal therapy, including lifestyle changes and combination drug therapy, combined in one tablet whenever possible; making greater use of the patient's capabilities and obtaining feedback from him interaction with pharmacists and nurses).
• Patient level (self and remote monitoring of blood pressure, use of reminders and motivational strategies, participation in educational programs, self-correction of therapy in accordance with simple algorithms for patients; social support).
• The level of therapy (simplification of therapeutic schemes, the "one pill" strategy, the use of calendar packages).
• The level of the healthcare system (development of monitoring systems; financial support for interaction with nurses and pharmacists; reimbursement of patients for fixed combinations; development of a national database of drug prescriptions available to doctors and pharmacists; increasing the availability of drugs).

• Expanding the possibilities for using 24-hour blood pressure monitoring and self-monitoring of blood pressure in the diagnosis of hypertension
• Introduction of new target BP ranges depending on age and comorbidities.
• Reducing conservatism in the management of elderly and senile patients. To select the tactics of managing elderly patients, it is proposed to focus not on chronological, but on biological age, which involves assessing the severity of senile asthenia, the ability to self-care and tolerability of therapy.
• Implementation of the “one pill” strategy for the treatment of hypertension. Preference is given to the appointment of fixed combinations of 2, and if necessary, 3 drugs. Starting therapy with 2 drugs in 1 tablet is recommended for most patients.
• Simplification of therapeutic algorithms. Combinations of a RAAS blocker (ACE inhibitor or ARB) with AKs and/or TDs should be preferred in most patients. BB should be prescribed only in specific clinical situations.
• Increasing attention to the assessment of patient adherence to treatment as the main reason for insufficient control of blood pressure.
• Increasing the role of nurses and pharmacists in the education, supervision and support of patients with hypertension as an important part of the overall strategy for BP control.

A recording of the plenary meeting of the 28th European Congress on Hypertension and Cardiovascular Prevention with the presentation of recommendations is available at http://www.eshonline.org/esh-annual-meeting/

Villevalde Svetlana Vadimovna – Doctor of Medical Sciences, Professor, Head of the Department of Cardiology, Federal State Budgetary Institution “N.N. V.A. Almazov" of the Ministry of Health of Russia.

Kotovskaya Yuliya Viktorovna - Doctor of Medical Sciences, Professor, Deputy Director for Research at the Russian Research Clinical Gerontological Center of the Russian National Research Medical University named after I. N.I. Pirogov of the Ministry of Health of Russia

Orlova Yana Arturovna – Doctor of Medical Sciences, Professor of the Department of Multidisciplinary Clinical Training, Faculty of Fundamental Medicine, Lomonosov Moscow State University, Head. Department of Age-Associated Diseases of the Medical Research and Educational Center of Moscow State University named after M.V. Lomonosov.