Clinic: Modern approaches to diagnostics and treatment of arterial hypertension” (second part)

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The second part of the article.

And here the question arises, do we really need to be treated if the person smokes, is there anything to help? It turns out that you need to fight always. Smokers 40% more likely to die from any cause; the people who left less than two years ago, but gave up — it is only +10%, and that left 2 years ago and more, there is no increased risk. That is, Smoking cessation is beneficial at any age, and if a person quits Smoking, of course, the forecast will improve.

It is best to quit Smoking and to be treated, but if a person does not quit Smoking, there are a number of drugs that significantly improve endothelial function, even in smokers patients, particularly effective drug Quinapril. The drug restores the flow-dependent dilation of the brachial artery in smokers and hypertensive patients not only reduces pressure, but also improves the function of blood vessels.

Hypertension is the second major risk factor. All ways to reduce the pressure the same? Today, there are recent recommendations — the recommendations of the British society for the study of hypertension, which differ significantly from what we knew before. Based on recent studies as a first line treatment for patients younger than 55 years, the use of ACE inhibitor or angiotensin receptor antagonist. For patients older than 55 years are offered a diuretic or calcium antagonist. At the second stage — a combination of two drugs, such as ACE inhibitor and a diuretic or the ACE inhibitor and calcium antagonist and finally the third stage is a combination of all three drugs — ACE inhibitor plus a diuretic plus a calcium antagonist. And then to enhance therapy — beta blockers, alpha blockers and aldosterone antagonists. Moreover, beta-blockers remain the preferred therapy in patients with combined hypertension and coronary artery disease. So, of course, these combinations will also help in reducing the pressure and preventing the risk of coronary complications.

Dyslipidemia is the third major risk factor, Many studies with statins for primary and secondary prevention of the disease in patients with and without myocardial infarction, with stroke and without stroke, with CHD and without CHD, diabetes, peripheral atherosclerosis and multiple risk factors confirm that, in all cases, overall mortality, heart attacks, strokes drop significantly. Effectiveness, safety in this case is obvious.

The second rule, which is now actively discussed — how to treat statin. Whether to treat them aggressively, as necessary, to achieve the target levels of lipids or not. In our country, when we assign 10 mg of simvastatin, something that nobody recommends that (in the UK this dose is sold in supermarkets as a food additive), we only pretend to treat atherosclerosis. All the recommendations start with 20 mg of simvastatin, and in fact, 40 mg, or recommend modern synthetic statins, e.g. atorvastatin. The more you lower cholesterol, the better. This applies to both the primary and secondary prevention. In the REVERSAL study, we investigated the effect of the level of plaque conventional statin therapy (pravastatin, reduces cholesterol LDL to 110 mg/DL) and aggressive therapy (atorvastatin, reduced the level of atherogenic lipids to 79 mg/DL).

Prescribing any therapy with statins, you still affect the course of atherosclerosis by half and slow down the growth of plaque in the coronary artery. But, of course, aggressive therapy better and allows you to completely stop the progression of atherosclerosis. In this case, the leader is atorvastatin and it is necessary to stress that especially the benefits of atorvastatin beneficial are in the highest risk groups. Patients with acute coronary syndrome after a heart attack right from the first day receive treatment with atorvastatin and the control group also received statins. The benefit of aggressive therapy with a high dose of atorvastatin is shown very quickly by the 15th day, and after 30 days of treatment the difference in the risk of death and cardiovascular complications between atorvastatin and pravastatin reaches statitics-ing significant differences. Therefore, atorvastatin is today the drug of choice for high-risk patients, particularly after acute myocardial infarction.

Another unique study AVERT, when patients with acute coronary syndrome were proposed two strategies: balloon dilatation of a coronary artery or treatment with a high dose of atorvastatin. Or surgery (catheter) against the tablet. In the beginning of the study all were convinced that the mechanical opening of the vessel better, but the angioplasty group lost to the group of aggressive therapy with atorvastatin 80 mg in order to reduce the level of cholesterol low-density lipoproteins to the level of 77 mg/DL. Therefore, statin therapy is obligatory in patients at high risk, with a history of heart attack, acute coronary syndrome, unstable angina, when there is a need for intervention. Aggressive therapy with atorvastatin allows to achieve high results of treatment.

To estimate total cardiovascular risk in Europe, implemented a SCORE system. This scoring system, it is made for two zones: the zone of low risk (this includes the 8 EU countries) and high risk zones, where the leader and Russia. On the basis of what determines the risk? This is the systolic pressure, total cholesterol, gender, status “Smoking/not Smoking” and age. For example, if we take the patient into low risk, who lives in Monaco: he is 55 years of age, Smoking, systolic blood pressure 160 mmHg, cholesterol 6 mmol/l, the risk had 6%. More than 5% is already a high — risk zone, and patient requires aggressive treatment. If he does not smoke, the risk is only 3%. If we go into a high area and take the same patient, who lives in Russia, the level of risk it will be 11 %, i.e. it is extremely high and requires aggressive treatment. This program allows you to enter all the data of the patient and to identify the level of risk, and then you can show how the risk will be reduced, if he quit Smoking or to take statins. Is a system of assessing complex risk factors. But there is one very important factor is insulin resistance, or now it is often like to call the metabolic syndrome, i.e. when the disorder of glucose metabolism leads to cardiovascular disease. Of course, leading to the epidemic of metabolic syndrome is obesity, an increased body weight. It is considered that most of these people living in the USA. They eat a lot of hamburgers and genetically engineered food, a little move, which is true. Therefore, in the US over the past 10 years dramatically increased the number of individuals with obesity and metabolic syndrome.

However, according to the work of the offices of pre-medical control in Moscow, for 8 years who examined more than 4 000 000 people, the number of people with increased body mass index increased from 18% in 1998 to 34% in 2009. Obviously, the problem exists not only in USA but also in Russia.

Abdominal type of obesity with the increase in the rate of visceral fat is nearly equivalent to the insulin resistance, that is, low sensitivity of peripheral tissues to insulin. Insulin resistance is considered a key moment in the development of endothelial dysfunction, atherosclerosis and cardiovascular diseases through many mechanisms. Therefore, the low sensitivity of tissues to insulin is a risk of increased pressure, and inflammation, and high cholesterol, and the risk of developing diabetes, and increased lipids, i.e. the development of atherosclerosis.

The world health organization in 1998 he published the book “Diagnosis, definition and classification of diabetes and its complications”, which tried to combine all this in the concept of the “metabolic syndrome.” Metabolic syndrome is, in the who, disturbed glucose metabolism is mandatory, it is diabetes or poor glucose tolerance or insulin resistance, plus obesity, plus disorders of the cardiovascular system: hyperlipidemia, high blood pressure and, in the original version, microalbuminuria. So it was classically. But given the changing situation in the world in 2005 at the 1st Congress on prediabetes and metabolic syndrome this concept is changed. Now in the first place — obesity is the only factor that needs to be in metabolic syndrome and the other two are elevated triglycerides or reduced cholesterol high density lipoproteins, hypertension, and hyperglycemia. That is, it turns out that today, if a person has an increased body mass, he’s got increased triglycerides and increased the pressure, without any detection of disturbed glucose metabolism we can make the diagnosis of metabolic syndrome. Although this interpretation raises questions, however, today it is the official definition.

We must also remember that a healthy lifestyle is an important part of treatment of patients with high risk, because physical activity and diet can help prevent the development of diabetes and cardiovascular disease.

Today are known three of the most famous studies: a Finnish study on the prevention of diabetes, an American study on diabetes prevention study and the Da Qing conducted in China. Imagine next to Finn, American and Chinese are totally different people who different eat and live differently, but, nevertheless, the results of all three studies were unique and the same — 58% reduction in risk of developing diabetes. Moreover, the use of Metformin as prevention is less profitable, that is, the best is to lose weight, doing exercise and keeping diet.

Even after myocardial infarction, if the person follows a healthy Mediterranean diet, the risk of recurrent acute myocardial infarction and cardiovascular complications is reduced by 47%. That is, the Mediterranean diet, which includes plenty of vegetables and fruits, fish, red wine and olive oil are very beneficial reduces the risk of further complications.

And finally, diabetes is a huge risk factor for death from cardiovascular complications. The risk of reinfarction in people who had already had myocardial infarction in anamnesis, increased 5 times. And the presence of type II diabetes also worsens the prognosis as myocardial infarction. When combined myocardial infarction and diabetes, the risk increases by almost 15 times.

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