Department of propaedeutics of internal diseases

DIAGNOSIS AND TREATMENT OF ARTERIAL HYPERTENSION IN

TABLES AND DIAGRAMS
Educational and methodological recommendations

Almaty 2025

1
UDC
BBK
Reviewers:

V.N. Abrosimov, MD, Professor, Head of the Department of Family

Medicine Therapy at the Faculty of Family Medicine;
M.A. Butov, MD, Professor, Head of the Department of Propaedeutics of
Internal Diseases

Compiled by:
A.A. Nizov, MD, Professor, Head of the Department of Internal Diseases and
Polyclinic Therapy;
N.S. Asfandiyarova, MD, Associate Professor of the Department of Internal
Diseases and Polyclinic Therapy;
E.I. Koldynskaya, PhD, Associate Professor of the Department of Internal
Diseases and Polyclinic Therapy.

Diagnosis and treatment of arterial hypertension in tables and diagrams:

educational and methodological recommendations on the specialty "Medical
science" (05/31/01) / compiled by: A.A. Nizov, N.S. Asfandiyarova, E.I.
Koldynskaya; GBOU VPO Ryazan State Medical University of the Ministry of
Health of the Russian Federation. Ryazan: RIO Ryazan State Medical University,
2016. 43 p.

The guidelines have been developed in connection with new advances in the
diagnosis and treatment of hypertension. The educational and methodological
recommendations can be used to train students of the 5th and 6th courses of the
Faculty of Medicine in internal Medicine (specialty "Medical science", code:
05/31/01).

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 INTRODUCTION

Chapter I. Classification of arterial hypertension 5

Chapter II. Diagnosis of arterial hypertension 6

Chapter III. Diagnosis of secondary arterial 12

hypertension 13

Chapter IV. Treatment of arterial hypertension 18

Security questions 42

References 43

The methodological recommendations "Diagnosis and treatment of

arterial hypertension in tables and diagrams" are aimed at the formation
of the following professional competencies: PC- 3, PC-4, PC-5, PC-11,
PC-12, PC-16, PC-17, PC-18, PC-19, PC-
20, PC-22, PC-24, PC-26

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ABBREVIATIONS

AH arterial hypertension
AD antihypertensive drugs
BP blood pressure
CA calcium antagonists
ACE angiotensin-converting enzyme
EH essential hypertension
DBP diastolic blood pressure
IHD ischemic heart disease
ISAH isolated systolic arterial hypertension
HDL high-density lipoproteins
VLDL very low-density lipoproteins
LDL low-density lipoproteins
MAU microalbuminuria
MS metabolic syndrome
IGT impaired glucose tolerance
ACVA acute cerebrovascular accident
TC total serum cholesterol
RAAS renin-aldosterone-angiotensin system
SBP systolic blood pressure
DM diabetes mellitus
FFA free fatty acids
ABPM ambulatory blood pressure monitoring
CVD cardiovascular disease
TG triglycerides
ULTRASONOGRAPHY ultrasound examination

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 INTRODUCTION
In recent years, there has been a significant increase in the
number of patients with cardiovascular diseases (CVD), an increase in
the incidence and prevalence of which is accompanied by an increase in
mortality. Arterial hypertension (AH) is one of the important
components of CVD.
Worldwide, there are more than 600 million people suffering
from hypertension, in Russia there are more than 40% of them. The
medical and social significance of this pathology leads to an intensive
study of the causes of the disease, clinic, diagnosis and treatment. In
recent years, new drugs and treatment regimens for hypertension have
appeared. For better assimilation of the material by students, there is an
urgent need for a compact presentation of information on the latest
advances in the diagnosis and treatment of hypertension in diagrams
and tables.

Definition: Arterial hypertension (AH) is commonly referred to as

a multifactorial, genetically determined disease characterized by a
persistent, chronic increase in systolic (140 mmHg or higher) and/or
diastolic (90 mmHg or higher) blood pressure (BP).

The syndrome of increased blood pressure is caused by either

"hypertension" (GB) or "symptomatic hypertension". The term
"hypertension", proposed by G.F.Lang in 1948, corresponds to the
concept of "essential hypertension", which is widespread in other
countries. GB is usually understood as a chronically occurring disease,
the main manifestation of which is hypertension, which is not associated
with the presence of pathological processes in which an increase in
blood pressure is caused by well-known, in modern conditions often
causes that can be eliminated, in this case we are talking about
"symptomatic hypertension"

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 Chapter 1. CLASSIFICATION OF ARTERIAL
HYPERTENSION
Classification of arterial hypertension by office blood pressure
In 1999, WHO and the International Society of Hypertension
proposed a classification of arterial hypertension by blood pressure
(Table 1). There are three degrees of hypertension. When making a
diagnosis, the degree of hypertension is indicated in Arabic numerals.
The degree of blood pressure is determined by the highest value of
systolic blood pressure (SBP) or diastolic blood pressure (DBP). If SAD
and DAD are in different categories, then you need to follow the
recommendations for the higher category.

Table 1. Classification of arterial hypertension by blood pressure level

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7
 Isolated systolic hypertension (ISAH) is common among patients
over 60 years of age and is characterized by increased SBP with normal
or low DBP. The degree of ISAG is determined by the highest value of
SAD.
Classification of arterial hypertension by cardiovascular risk

The severity of hypertension, treatment tactics, and prognosis, in

addition to blood pressure, determine cardiovascular risk, which is the
risk of developing cardiovascular complications and death from them in
the next 10 years. Risk stratification requires information on risk factors,
target organ damage (Fig. 1), the presence of metabolic syndrome (MS),
diabetes mellitus (DM), and associated clinical conditions (ACS).

Table 2 presents the criteria for risk stratification.

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 Table 2. Risk stratification criteria

Risk factors
• The value of pulse pressure in the elderly (> 60 mmHg)
• Male
• Age (≥55 years for men, ≥65 years for women)
• Smoking
• Dyslipidemia: Total cholesterol >4.5 mmol/L and/or LDL
Cholesterol >3 mmol/L and/or HDL Cholesterol<1.0 mmol/L in men,
< 1.2 mmol/L in women, and/or Triglycerides >1.7 mmol/L
• Fasting plasma glucose 5.6-6.9 mmol/l
• NTG
• Obesity (BMI ≥30 kg/m2)
• Abdominal obesity (waist circumference ≥102 cm for men and ≥88
cm for women) in the absence of MS
• Family history of cardiovascular diseases

Target organ damage

Heart (left ventricular hypertrophy)

• ECG: Sokolov-Lyon sign>38 mm; Cornell product>2440 mm x ms

• EchoCG: LVEF ≥125 g/m2 for men and ≥110 g/m2 for women

Vessels

• ULTRASOUND-signs of thickening of the artery wall (TIM>0.9

mm) or atherosclerotic plaques of the main vessels
• Pulse wave velocity from carotid artery to femoral artery >12 m/s
•Ankle/shoulder index<0.9

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Kidneys

• slight increase in serum creatinine:

• 115-133 mmol/L for men or 107-124 mmol/L for women
• low GFR<60ml/min/1.73 m2 (MDRD formula) or low creatinine
clearance<60ml/min (Cockcroft-Gault formula)
• MAU 30-300 mg/day;
• urinary albumin/creatinine ratio≥22 mg/g (2.5 mg/mmol) for men and
≥31 mg/dayg (3.5 mg/mmol) for women

Brain
 memory impairment, cognitive disorders, etc.

Diabetes mellitus

 fasting plasma glucose ≥7.0 mmol/L with repeated changes

and/or HbA1c ≥ 6.5%

 plasma glucose after meals or 2 hours after ingestion of 75 g

glucose ≥ 11.1 mmol/l

Metabolic syndrome
• Main criterion: abdominal obesity (FROM>94 cm for men; > 80
cm for women)
• Additional criteria: blood pressure≥130/85 mmHg, LDL
cholesterol>3.0 mmol/L, HDL cholesterol<1.0 mmol/L for men
or < 1.2 mmol/L for women, TG >1.7 mmol /L, fasting
hyperglycemia ≥6.1 mmol / L, plasma HTG — glucose 2 hours
after ingestion of 75 g of glucose≥7.8 and ≤11.1 mmol/l
• *The combination of the main and 2 of the additional criteria
indicates the presence of a metabolic syndrome

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 Associated clinical conditions

Diseases of the cerebral vessels (CVB)

• ischemic MI
• hemorrhagic MI
• TIA
Heart diseases
• THEM
• Angina pectoris
• Coronary revascularization
• HSN
Kidney diseases
• diabetic nephropathy
• kidney failure: serum creatinine>133 mmol/L (1.5mg/dl) for men
and>124 mmol/L (1.4 mg/dl) for women
Diseases of peripheral arteries:
• delaminating aortic aneurysm
• symptomatic lesion of peripheral arteries
Hypertensive retinopathy
• hemorrhages or exudates
swelling of the nipple of the optic nerve

Depending on the degree of increase in blood pressure, the

presence of risk factors, target organ damage, and associated clinical
conditions, all patients with hypertension can be classified into one of
four risk groups: low, medium, high, and very high additional risk
(Table 3). According to the Framingham model, low risk corresponds to
the likelihood of developing cardiovascular complications and death
from them over the next 10 years are less than 15%, the average risk is
15-20%, the high risk is 20-30%, and the very high risk is more than
30%. In the diagnosis, the risk is indicated in Arabic numerals: 1,2,3,4.
When assessing the amount of risk using the SCORE (Systematic
Coronary Risk Assessment) model, gender, age, and status are taken into
account.
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smoking, blood pressure and total cholesterol levels. For the Russian
Federation, according to the SCORE system, a low risk corresponds to a
probability of death within the next 10 years of less than 1%, an average
risk of 2-4%, a high risk of 5-9%, and a very high risk of 10% or more.

Table 3. Stratification of cardiovascular risk in hypertension

Classification of arterial hypertension by stages

The division into stages is possible only for hypertension; for

symptomatic hypertension, the stage is not indicated. There are three
stages of hypertension.

Table 4. Classification of hypertension by stages

Stage I: Increased blood pressure, without damage to target organs, in
the presence of risk factors. Target organs include: brain, heart,
kidneys, blood vessels
Stage II: target organ damage (symptoms), without associated clinical
conditions or associated Diseases

Stage III: target organ damage in the presence of associated clinical

conditions

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 Chapter II. DIAGNOSIS OF ARTERIAL HYPERTENSION

Patients with arterial hypertension are subjected to tests that

include laboratory and instrumental research methods (Table 5).

Table 5 Laboratory and instrumental research methods

1. Mandatory research:
 General blood test
 Biochemical blood analysis (fasting plasma glucose, total
cholesterol, LDL cholesterol, HDL cholesterol, serum
triglycerides, serum creatinine, serum uric acid, serum
potassium and sodium)
 General urinalysis, including analysis for microalbuminuria
 determination of creatinine clearance (according to the
Cockcroft-Gault formula*) or glomerular filtration rate
(according to the MDRD formula);
 12-lead ECG
2. Research recommended additionally:
 Glycated hemoglobin
 Quantitative analysis of proteinuria, potassium and sodium
in urine and their ratio
 Home and daily blood pressure monitoring
 Echocardiography
 Holter ECG monitoring (in case of arrhythmias)
 Ultrasound examination of the carotid arteries

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  Pulse wave velocity measurement
 Ankle-shoulder index
 Fundoscopy (fundus examination)
3. In-depth examination includes:
 complicated HYPERTENSION - assessment of the
condition of the brain, myocardium, kidneys, and main
arteries (ultrasound of the kidneys and adrenal glands,
ultrasound of the brachiocephalic and renal arteries, chest
X-ray;
 detection of secondary forms of hypertension - blood
concentrations of aldosterone, corticosteroids, and renin
activity; determination of catecholamines and their
metabolites in daily urine and/or blood plasma;
abdominal aortography; CT or MRI of the adrenal glands,
kidneys, and brain, CT or MR angiography.
Special research methods are shown when:
 suspicion of secondary hypertension;
 rapid increase in previously benign hypertension;
 the presence of crises with pronounced vegetative
manifestations;
 Grade III hypertension and hypertension that is
refractory to drug therapy;
 sudden development of hypertension.

*Creatinine clearance is calculated using the Cockcroft-Gault

formula (ml/min) = 88x (140-age, years) x body weight, kg / 72 x
creatinine, mmol/L.

For women, the result is multiplied by 0.85.

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 Chapter III. DIAGNOSIS OF SECONDARY ARTERIAL
HYPERTENSION

Common signs of secondary or symptomatic hypertension are

young age, high levels of hypertension, resistance to therapy, and
malignancy.
The causes of increased blood pressure in this case may be kidney
disease, renal vascular damage, pheochromocytoma, primary
hyperaldosteronism, Itsenko-Cushing's syndrome and disease, aortic
coarctation, and various medications (Table 6).

Indications for hospitalization of patients with arterial hypertension

are presented in Table 7.

Table 7. Indications for hospitalization of patients with hypertension

Indications for planned hospitalization:

Sudden onset of hypertension with high blood pressure

Stable hypertension with diastolic blood pressure > 115

mmHg.

Progression and resistance to drug treatment (refractory

hypertension)Frequent hypertensive crises (HA) Presence of
arterial vascular murmurs

Decrease in serum potassium <3.5 mmol/l

Clinical signs of endocrinopathy

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 Indications for emergency hospitalization:

Hypertensive crisis with pronounced manifestations of

hypertensive encephalopathy;

Complications of GB that require intensive care and regular

medical care: brain stroke, Suba-rahnoid hemorrhage, acute
visual disturbances, pulmonary edema, etc.

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 Table 6. Diagnosis of secondary hypertension
Parenchymal kidney Renal artery stenosis Primary Pheochromocytoma Cushing's
diseases hyperaldosteronism syndrom
e

Medical history Urinary tract Fibromuscular Muscle weakness, Paroxysmal Rapid weight gain,
infection or dysplasia, earlyonset of inheritance of early hypertension or polyuria,
obstruction, hypertension, especially hypertension and crises on the polydipsia, mental
hematuria, in women CVB background of disorders
painkiller abuse, events before the age constant
polycystic kidney Atherosclerotic of 40 hypertension,
disease stenosis: sudden onset hereditary
of hypertension, pheochromocytom
worsening of blood a
pressure control,
sudden pulmonary
edema
Physical Abdominal Noise in the projection Arrhythmia (with Skin Characteristic
examination formations (with of the renal artery severe hypokalemia) manifestations of appearance (central
polycystic kidney neurofibromatosis obesity, hirsutism,
disease) (coffee-colored striae)
spots,
neurofibromas

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Results Protein in urine, Difference in kidney Hypokalemia, Accidental opening Hyperglycemia
laboratory and red blood cells or length >1.5 cm renal accidental discovery of a formation in
Insta- rumental leukocytes, SCF ultrasound), rapid of mass in the adrenal the adrenal glands
research methods decreased deterioration of kidney gland (rarely outside
function them) -
(spontaneously or with
the administration of
Raas inhibitors)

Examination of of kidney Duplex Doppler Ratio of aldosterone Determination of Daily excretion of

the 1st line ultrasound ultrasound of the to renin under the proportion of cortisol in the urine
kidneys standardized metanephrins in
conditions urine or free
metanephrins in
plasma
(intermediate
metabolite)
catecholamines)

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The complement Detailed examination Magnetic resonance Confirmatory tests CT or MRI of the Samples with dec
modern for kidney disease angiography, multipiral (with sodium abdominal stripe with sametazone
examination (Nechiporenko Ave., CT, intraarterial digital loading, with and pelvis,
methods Zimnitsky Ave., IV subtraction fludrocortisone scintigraphy,
angiography urography, CT, MRI, suppression, genetic screening
etc.) captopril test), CT for pathological
of the adrenal mutations
glands, selective
blood sampling
from
the adrenal veins

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 Chapter IV. TREATMENT OF ARTERIAL HYPERTENSION
The main goal of hypertension treatment is to maximize the risk of
developing cardiovascular complications, lower blood pressure, and improve
quality of life. Along with lowering blood pressure to the target level, it is
necessary to correct modifiable risk factors.

Management tactics for a patient with a newly diagnosed increase in

blood pressure

Anamnesis collection and examination of the patient (if there is a crisis,

its relief). Referral of the patient for mandatory laboratory tests and
instrumental diagnostic methods. A week later, upon receipt of the results, a
diagnosis of "Essential arterial hypertension" ("hypertension") or a search for
the cause of symptomatic hypertension.

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 The tactics of managing patients with hypertension depending on the risk
of cardiovascular complications and the treatment algorithm are shown in Fig.
2 and Table 8.

Table 8. Management tactics of patients with hypertension depending on

the risk of cardiovascular complications

FR, Blood pressure, mmHg

POM
and SZ
AH of the 1st АH of the 1st АH 3 of the 1st
degree degree degree≥180/110
140−159/90−99 160−179/100−109
No FR Lifestyle change Lifestyle change Lifestyle change
for several months, for a few + start drug
if there is no blood weeks, in the therapy
pressure control, absence of blood immediately
start drug therapy pressure control
, start drug therapy

1−2 FR Lifestyle change Lifestyle change Lifestyle change

for several weeks, for several weeks, + start drug
in the absence of in the absence of therapy
blood pressure blood pressure immediately
control, start drug control, start drug
therapy therapy

≥3 Lifestyle change + Lifestyle change + Lifestyle change +

FR, start drug therapy start drug therapy start drug therapy
POM immediately immediately immediately
and SZ

АКС Lifestyle change + Lifestyle change + Lifestyle change +

start drug therapy start drug therapy start drug therapy
immediately immediately immediately

Lifestyle changes are recommended for patients (Table 9).

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Table 9. Non-drug treatment methods
 Limit salt intake to 5 g/day
 Limiting alcohol consumption to no more than 20-30
g/day (ethanol) for men and no more than 10-20
g/day for women
 It is recommended to increase the consumption of
vegetables, fruits, and low-fat dairy products
 In the absence of contraindications, it is
recommended to reduce body weight to a BMI of 25
kg/m2, and waist circumference to 102 cm for men
and 88 cm for women.
 Regular physical activity is recommended, for
example, at least 30 minutes of moderate dynamic
physical activity for 5-7 days a week.
 It is recommended to give all smokers advice on
quitting smoking and offer them appropriate
assistancemeasures

Along with recommendations for lifestyle changes, medical

treatment methods are used. Currently, five main classes of AHP are
used for the treatment of hypertension: angiotensin converting enzyme
(ACE) inhibitors, AT1 receptor blockers (ARBs), calcium antagonists
(AK), beta-blockers (beta-AB), diuretics (Tables 10, 11). Alpha-
blockers and imidazoline receptor agonists can be used as additional
classes of AGP for combination therapy.
Choosing the starting therapy to achieve the target blood
pressure level
In low/medium-risk hypertension, treatment begins with
monotherapy; if ineffective, the full dose is prescribed, or a second dg
is added. In high-risk/very high-risk hypertension, treatment should
start with 2 medications.if ineffective, the same combination of drugs
in the full dose or the addition of a third drug in the starting dose. If
there is no effectiveness, transfer to another combination of 2 or 3
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 drugs in a full dose. Target blood pressure levels are taken into account
(Table 12).

The choice of pharmacotherapy for hypertension

The main advantages of antihypertensive therapy are due to a decrease in blood

pressure and do not depend in principle on which classes and specific drugs are
used for this purpose. The primary indications and contraindications are taken
into account (Tables 13, 14).

Table 10. The main groups of antihypertensive agents

Doses, mg /day Doses, mg /day

Medication (frequency of Medication (frequency of
administration administration
per day) per day)
Diuretics Calcium antagonists

Amiloride 5 – 10 (1) Verapamil 120 – 480 (2 - 3)

Hydrochlorothiazi 12,5 – 50 (1) Verapamil-retard 120 – 480 (1)

de
Indapamide 2,5 (1) Diltiazem 180 - 360 (2 - 3)

Indapamide retard 1,5 (1) Diltiazem-retard 120 – 360 (1 - 2)

Xypamide 10 – 40 (1) Nifedipine-retard 30 – 120 (1)

Triamterene 12,5 – 50 (1) Amlodipine 2,5 – 10 (1)

Torasemide 2,5 – 10 (1) Isradipine 5 – 20 (2)

Furosemide 40 – 240 (2 – 3) Lacidipine 2 – 4 (1)

Chlorthalidone 12,5 – 50 (1) Felodipine 2,5 – 20 (1)

Spironolactone 2,5 – 100 (1 – 2) ACE inhibitors

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 - Adrenoblockers Captopril 25 – 150 (2 – 3)

Acebutolol 200– 800 (1 – 2) Enalapril 5 – 40 (1 – 2)

Atenolol 25 – 100 (1 – 2) Spirapril 3 – 6 (1)

Betaxolol 5 – 20 (1) Lisinopril 2,5 – 40 (1)

Bisoprolol 2,5 – 10 (1) Moexipril 7,5 – 15 (1)

Metoprolol 50 – 300 (2) Perindopril 4 – 8 (1)

I got it 80 – 240 (1 – 2) Ramipril 1,25 – 20 (1)

Nebivolol 2,5 – 5 (1) Benazepril 5 – 40 (1 – 2)

Pindolol 10 – 60 (2) Fosinopril 10 – 40 (1)

Propranolol 40 – 320 (2 – 3) Cilazapril 2,5 – 5 (1)

Sotalol 80 – 160 (1 – 2) AT1 - receptor blockers

Celiprolol 200 – 400 (1 – 2) Valsartan 80 – 160 (1)

-- Adrenoblockers Losartan 25 – 100 (1 – 2)

Carvedilol 12,5 - 50 (2) Irbesartan 150 – 300 (1)

Imidazoline receptor agonists Candesartan 8 – 16 (1)

Moxonidine 0,2 – 0,4 (1 – 2) Telmisartan 40 – 80 (1)

Rilmenidine 1 – 2 (1 – 2) Eprosartan 400 – 1200 (1 –

2)

Centrally acting drugs 1-Аdrenoblockers

Guangfacing 0,5 – 6 (1 – 2) Doxazosin 1 – 16 (1)

Clonidine 0,2 – 1,2 (2 – 3) Prazosin 0,5 – 20 (2 – 3)

Methyldopa 500 – 3000 (2) Terazosin 1 – 10 (1)

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 Table 11. Diuretics used for long-term hypertension therapy

Average
Drugs doses of Characteristic side effects
mg /day
Thiazide and thiazide-like diuretics
Hydrochlorothiazide 12,5 - 50 Hypokalemia, hypomagnesemia,
Indapamide 1,25 - 5 hyperuricemia, impaired
10 - 20 glucose tolerance, hypertriglyceridemia,
Clopamide impotence, hyponatremia, hypochloremic
Xypamide 10 - 40 alkalosis (indapamide causes minor changes
Metolazone 2,5 - 5 in blood lipid composition).
Chlorthalidone 12,5 - 50
Loop diuretics
Bumetanide 0,5 - 4 Hypotension, hypokalemia,
Torasemide 2,5 - 10 hypomagnesemia, hyperuricemia,
hyponatremia, impaired
Furosemide 40 - 240 glucose tolerance,
Ethacric acid 25 - 100 hypochloremic alkalosis, hypercalciuria,
hearing loss
Potassium-sparing diuretics
Amiloride 5 - 10 Hyperkalemia, hyponatremia,
hyperchloremic alkalosis
Triamterene 25 - 100 The same + kidney damage (rare)
Spironolactone 25 - 100 The same + gynecomastia, impaired sexual
function in men, hirsutism and
dysmenorrhea in women

Table 12. Target blood pressure levels, mmHg

Patient group Target blood pressure
The general population of patients with < 140/90
hypertension
HYPERTENSION + diabetes mellitus < 130/85
without proteinuria
HYPERTENSION + diabetes mellitus
with proteinuria < 125/75

AG + CPN < 125/75

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 Table. 13. Preferred indications for prescribing various groups of antihypertensive drugs
IAPF BRA β-АB AK
(dihydropyridine)
• HSN • HSN  Coronary heart
• LV dysfunction • Transferred by HIM disease • ISAG
• Coronary heart disease • Diabetic nephropathy  Transferred by (elderly)
• Diabetic nephropathy • Proteinuria/MAU HIM • Coronary heart disease
• Nondiabetic nephropathy • GLJ  HSN • GLJ
• LVH • Atrial fibrillation  Tachyarrhythmia • atherosclerosis of the
• Atherosclerosis of the carotid • MS s carotid and coronary
arteries • Cough when taking ace  Glaucoma arteries
• Proteinuria/MAU inhibitors  Pregnancy Pregnancy
• Atrial fibrillation
• SD
• MS

AK (verapamil/diltiazem) Thiazide diuretics Diuretics (aldosterone Loop diuretics

antagonists)
• Coronary heart disease • ISAG (elderly) • The final stage of CRF
 CHF • CHF
• Atherosclerosis of the carotid • HSN
arteries • Transferred by HIM
 • Supraventricular
tachyarrhythmias

24
 Table 14. Contraindications to prescribing various groups of
antihypertensive drugs
Thiazide diuretics
 Gout*
 Metabolic syndrome
 Impaired glucose tolerance
 Pregnancy
 Hypercalcemia
 Hypokalemia

Long-lasting AK

• AV block (grade 2 or 3, trifascicular block)*

• Severe left ventricular dysfunction*
• Heart failure*
• Tachyarrhythmia (for dihydroperidine AK)

ACE inhibitors
 Pregnancy*
 Angioedema*
 Hyperkalemia*
 Bilateral renal artery stenosis*
 Women capable of childbearing

β- blockers
 • Bronchial asthma*
 • AV block (2nd or 3rd degree) Metabolic syndrome (except nebivolol)
 • Athletes and physically active patients
 • COPD (except nebivolol)

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Angiotensin II receptor blockersPregnancy*
 Hyperkalemia*
 Bilateral renal artery stenosis*
 Women capable of childbearing

Antagonists of mineralocorticoid receptors

• Acute or severe renal insufficiency (GFR
<30 ml/min)
• Hyperkalemia
* - an absolute contraindication

Along with monotherapy, various combinations of

antihypertensive drugs are used (Fig. 3, Tables 15, 16).

3 Possible combinations of different classes of antihypertensive

agents.

26
The most rational combinations are shown in solid lines. The rectangles indicate the classes whose
effectiveness has been proven in controlled studies.

27
 Table 15. Combinations of antihypertensive drugs
Rational combination (effective) ACE inhibitor +diuretic;
ARB + diuretic;
ACE inhibitor + AK;
БРА +АК;
Dihydropyridine AK
+β-AB;
AK + diuretic;
β-AB + diuretic;

Possible combination Dihydropyridine AK + non-

dihydropyridine AK;
ACE inhibitors + β-AB;
ARB + β-AB;
ACE inhibitor + ARB;
Direct renin inhibitor or alpha-
adrenoblocker with all major
classes of AHP

An irrational combination β-AB +

non-dihydropyridine AK;
ACE inhibitors + potassium-
sparing diuretic;
β-AB + is a centrally acting drug.

Table. 16. Combinations of 3-component therapy

ACE inhibitor + dihydropyridine AK+ β-AB;
BRA + dihydropyridine AK + β-AB;
ACE inhibitor + AK + diuretic;
ARB + AK + diuretic;
Ace inhibitor + diuretic + β-AB;
ARB + diuretic + β-AB;
dihydropyridine AK + diuretic + β-AB.

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 One of the 3 drugs, as a rule, should be a diuretic. For combination
therapy of hypertension, both non-fixed and fixed combinations of drugs
can be used. However, preference should be given to fixed combinations
of antihypertensive drugs containing 2 drugs in one tablet. The
appointment of a fixed combination of two AHPs may be the first step of
treatment in patients with high cardiovascular risk or may follow
monotherapy immediately.

TREATMENT OF ARTERIAL HYPERTENSION IN

PATIENTS WITH CONCOMITANT PATHOLOGY
Table 17. Recommendations on the choice of medications for the
treatment of patients with hypertension, depending on the clinical
situation
Damage to target organs
GLJ БРА, ACE inhibitors, АК
Asymptomatic atherosclerosis АК, ACE inhibitors
MAU ACE inhibitors, БРА
Kidney damage ACE inhibitors, БРА
Associated clinical conditions
Previous MI Any antihypertensive drugs
Preceding THEM β-AB, ACE inhibitor, BRA
Coronary heart disease β-AB, AK, ACF, BRA
HSN Thiazide diuretics, β-AB, ACE inhibitors, ARBs,

Atrial fibrillation aldosterone antagonists

is paroxysmal IAPF, WALL LAMP

Atrial fibrillation is constant β-AB, non-dihydropyridine AK

Kidney Ace inhibitors, ARBs, loop diuretics

Special clinical situations

The elderly ARBs, AK, thiazide diuretics
ISAG AK, thiazide diuretics
ms WALL LAMP, IAPF, AK
SD WALL LAMP, ACF
Pregnancy AK, methyldopa, β-AB

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 For more detailed treatment of patients with hypertension and
concomitant pathology, see tables 18-34.

Table 18. Treatment of hypertension in patients with left

ventricular hypertrophy
ARBS II

ACE inhibitors

long-acting AC

indapamide

If it is not effective, it is a combination:

ARB II/ACE inhibitors + thiazide diuretics or AC

ARB II/ACE inhibitors + thiazide diuretics + AC

ARB II/ACE inhibitors + thiazide diuretics + AK + aldosterone antagonists

(preferably eplerenone)

Table 19. Treatment of hypertension in patients with asymptomatic

atherosclerosis

Long-acting AC and ACF

If ineffective, a combination of

ace inhibitors + AK

30
 Table 20. Treatment of hypertension in patients with
microalbuminuria

iAPF BRA II

If ineffective, a combination of

ace inhibitors / ARBS II + indapamide

ARB II/ACE inhibitor + indapamide + AK (verapamil) or beta-blocker

(nebivolol or carvedilol) at heart rate > 84 beats/min

Table 21. Treatment of hypertension in patients with a history of

stroke

Any drug or rational combinations of them that effectively

reduce blood pressure

Table 22. Treatment of hypertension in patients with a history of

myocardial infarction

β- blocker

iAPF

BRA II

31
 Table 23. Treatment of hypertension in patients with coronary
artery disease (stable angina pectoris)

β-blockers

Long-lasting AK
In case of inefficiency, a combination:

beta-blocker/AK (undesirable in CHF) +ARB II/ACE inhibitors

β-blocker + AK (preferably dihydropyridine AK)

beta-blocker + ARB II/ACE inhibitors + mineralocorticoid receptor

antagonists (preferred for CHF)

Table 24. Treatment of hypertension in patients with atrial

fibrillation (prevention)
iAPF BRA II

The beta-blocker

Antagonists of mineralocorticoid receptors

In case of inefficiency, a combination:

ARB II/ACE inhibitor + beta-blocker

ARB II/ACE inhibitor + beta-blocker + mineralocorticoid receptor

antagonists

32
 Table 25. Treatment of hypertension in patients with CHF (systolic
dysfunction)
iAPF BRA II

beta-blocker Diuretic

Antagonists of mineralocorticoid receptors

In case of inefficiency, a combination:

ARB II/ACE inhibitor + beta-blocker/diuretic

ARB II/Ace inhibitor + beta-blocker +diuretic ARB II/Ace inhibitors

+ beta-blockers/diuretic

ARB II/ACE inhibitor + beta-blocker + diuretic + mineralocorticoid

receptor antagonists

Table 26. Treatment of hypertension in patients with nondiabetic

CKD

iAPF BRA II

In case of inefficiency, a combination:

ARBS II/ACE inhibitors + thiazide diuretics

33
 Table 27. Treatment of hypertension in diabetes mellitus (including
diabetic nephropathy)

iAPF BRA II

If ineffective, a combination of

ace inhibitors / ARBS II + thiazide diuretics (indapamide is

preferred) / AK

Ace inhibitors/ARBS II + thiazide diuretics (indapamide is preferred)

+ AK

ARB II/ACE inhibitor + indapamide + AK (preferably verapamil) or

beta-blocker (preferably nebivolol or carvedilol) at heart rate > 84
beats/min

!!! Careful monitoring of creatinine and potassium levels in CKD is

recommended when using ace inhibitors/ARBS II
!!! If the creatinine level is more than 150 mmol/l or the creatinine
clearance is below 30 ml/min, loop diuretics should be replaced with
thiazide diuretics if necessary.

Table 28. Treatment of hypertension in hyperuricemia/gout

BRA II (losartan is preferred)

In case of inefficiency, a combination:

WALL LAMP II + AK

BRA II + AK + indapamide

ARB II + AK + indapamide + beta-blocker (nebivolol or carvedilol

are preferred)
34
 Table 29. Treatment of hypertension in metabolic syndrome

iAPF BRA II

Long-lasting effects

If ineffective, a combination of

ace inhibitors / ARBS II + thiazide diuretics (indapamide is preferred) /

AK

Ace inhibitors/ARBS II + thiazide diuretics (indapamide is preferred)

+ AK

ARB II/ACE inhibitor + indapamide + AK or beta-blocker (nebivolol

or carvedilol) at heart rate > 75 beats/min

Table 30. Treatment of hypertension in obesity

ACE inhibitors (perindopril and ramipril are preferred)

BRA II (telmisartan and irbesartan are preferred) If ineffective, a

combination of:

Ace inhibitor / ARB II + indapamide / AK Ace inhibitor / ARB II +

indapamide + AK
ARB II/ACE inhibitor + indapamide + AK or beta-blocker
(nebivolol or carvedilol are preferred) at heart rate > 75 beats/min

35
 Table 31. Treatment of hypertension in patients with ISAG and
elderly patients

Thiazide diuretic Long-acting drugs

If ineffective, a combination of: AK

+ thiazide diuretic AK / thiazide

diuretic + ARB II / ACE inhibitor

AK + thiazide diuretic + ARB II/ACE inhibitors

Elderly and senile patients with hypertension with SAD ≥ 160

mmHg are recommended to reduce SAD to 140-150 mmHg

In patients with hypertension aged < 80 years who are in

satisfactory general condition, antihypertensive therapy may be
considered appropriate for SAD ≥ 140 mmHg, and target levels of SAD
can be set to <140 mmHg if the therapy is well tolerated.

Table 32. Treatment of hypertension associated with stroke

In case of cancer, transient ischemic attack, blood pressure target <
140/90 mmHg, a combination of ace inhibitors/diuretics is preferable
In acute ischemic stroke, a decrease in the extreme increase in blood
pressure (SAD > 220 mmHg, DBP >120 mmHg) by 15-25% in the
first 24 hours, with a gradual decrease thereafter.

Thrombolytic therapy – if indicated

36
 Table 33. Treatment of hypertension during pregnancy

Methyldopa

Long-acting drugs beta-blocker

(nebivolol or carvedilol arepreferred)

Labetalol (according to international

recommendations),

If ineffective, a combination of:

Methyldopa + AK

!!! In urgent cases (preeclampsia, eclampsia), the drug of choice is

labetolol, you can also use sodium nitroprusside, nitroglycerin IV

!!! Ace inhibitors, ARBS II, and thiazide diuretics are contraindicated.

Table 34. Treatment of resistant hypertension

Hypertension is considered resistant if lifestyle changes + 3

antihypertensive drugs (including diuretics) do not reduce blood pressure
to 140/90 mmHg.

We consider the drug options that the patient is taking, adjust them
according to the following table:

37
Isolated hypertension, Ace inhibitors/ARBs+AK+diuretics
(indapamide)
diabetes
Metabolic syndrome
CHD Ace inhibitors+beta-blockers+AK

ARBs/ACE
Insulin resistance
inhibitors+indapamide+AK/moxoni din

Obesity ARBs/ACE
inhibitors+beta-blockers/moxonidine

And, if such a three-component scheme does not work, we add

antagonists of mineralocorticoid receptors (potassium-sparing
diuretics-amiloride), an alpha-blocker (doxazosin), anatagonists of
imidosaline receptors (moxonidine)

HYPERTENSIVE CRISES
There are complicated and uncomplicated hypertensive crises.
Complicated hypertensive crises are called marked increases in blood
pressure, accompanied by damage to target organs. Immediate
reduction of blood pressure to prevent the progression of damage to
target organs is necessary in acute coronary syndrome, exfoliating
aortic aneurysm, hypertensive encephalopathy, acute cerebral
infarction, intracranial hemorrhage, severe arterial bleeding, eclampsia
(Table 35).
Uncomplicated hypertensive crises are characterized by a
marked increase in blood pressure (>180/120 mmHg) withoutsigns of
acute damage to the target organs. In uncomplicated hypertensive
crises, blood pressure decreases with the help of oral medications
without hospitalization.
38
Table 35. Complicated hypertensive

Hypertensive encephalopathy Associated lesions of

target organs:
• Acute coronary syndrome
• pulmonary edema
• dissection of the aortic aneurysm
• intracranial/subarachnoid hemorrhage
• acute cerebral infarction
• acute or rapidly progressing renal failure

Криз при феохромоцитоме

Guillain–Barre syndrome Spina
cord injury
Drug-induced hypertension
(sympathomimetics, cocaine,
phencyclidine,
phenylpropanolamine, LSD,
cyclosporine, withdrawal of
antihypertensive drugs,
monoamine oxidase inhibitors)
Eclampsia
Postoperative bleeding
Hypertension after coronary
bypass surgeryТравма

39
Table 36. Medicines for the treatment of complicated hypertensive crisis

Medication Dose The Duratio Side effects

beginning n
of the
action
Sodium immediatel 1-2 min Hypotension, vomiting,
nitroprusside Dose y cyanide intoxication
0,25–10
mcg / kg /

Labetalol Mi n 5-10 min 2-6 days Nausea, vomiting,

20-80 mg atrioventricular
Bolusnoi blockages, bronchospasm
1-2
mg / min
infusion
Nitroglycer in 5–100 1-3 min 5–15 Headache, vomiting
MCG / min
min
Enalaprilate 1,25-5 mg 15 min 4-6 hours Hypotension,
bolyusno angioedema, renal
failure

Furosemide 40-60 mg 5 min 2 hours Hypotension

Phenoldopam 0, 1–0,5 5-10 min 10–15 Hypotension,
mcg / kg / min headache
Mi n

Nikardipin 2-10 mg / hr 5-10 min 2-4 hours Reflex

tachycardia, redness
of the face

Hydralazine 10-20 mg 10 min 2-6 hours Reflex

bolyusno tachycardia

Phentolamine 5–10 1-2 min 3-5 min Reflex

mg / min tachycardia

Urapidil 25-50 mg 3-4 min 8–12 ч Sedation

bolyusno

40
Examples of diagnostic findings are presented in table 38.

Table 38. Examples of diagnostic conclusions:

 GB of stage II. Degree of hypertension 3. Dyslipidemia.
Hypertrophy of the left ventricle. Risk 4 (very high)

 GB of stage III. Degree of hypertension 2. Coronary heart

disease: Angina pectoris II FC. Risk 4 (very high)

 GB of stage II. Degree of hypertension 2. Atherosclerosis

of the aorta, carotid arteries. Risk 3 (high).

 GB of stage III. Degree of hypertension 1. Obliterating

atherosclerosis of the vessels of the lower extremities.
Intermittent lameness. Risk 4 (very high).

 GB of stage I. Degree of AG 1. DM type 2. Risk 4 (very

high).

 Coronary heart disease. Angina pectoris of tension III FC.

Postinfarction (large focal) and atherosclerotic
cardiosclerosis. GB of stage III. Degree of hypertension 2.
Risk 4 (very high).

41
 CONTROL QUESTIONS

1. Name the target organs suffering from hypertension.

2. Name the research methods for target organ damage.
3. Specify the criteria for dividing the I, II, and III stages of hypertension.
4. How is the risk of developing cardiovascular complications in
hypertension determined (SCORE system and Framingham model)
5. What causes can lead to the development of symptomatic hypertension
6. What laboratory and instrumental research methods are used to detect
kidney damage?
7. Make a differential diagnosis between pheochromocytoma and
hypertension.
8. Determine the tactics of managing a patient with a newly detected increase
in blood pressure.
9. Name non-drug treatments for hypertension.
10. Which groups of antihypertensive drugs are used in the treatment of
hypertension?
11. Name the preferred indications for the use of antihypertensive drugs.
12.What are the absolute and relative contraindications for the use of
antihypertensive drugs?
13. What does a rational, possible and irrational combination of
antihypertensive drugs mean?
14. What is resistant hypertension? Methods of her treatment.
15. Name the indications for planned and emergency hospitalization for
hypertension.

42
 LIST OF LITERATURE
1. Algorithms for managing a patient with arterial hypertension.
Antihypertensive League, an all-Russian public organization for the
Promotion of the Prevention and Treatment of Hypertension – St.
Petersburg, 2015. – The first edition. – 52 p .
2. Diagnosis and treatment of arterial hypertension. Russian
recommendations (fourth revision) The Russian Medical Society for
Arterial Hypertension and the All–Russian Scientific Society of
Cardiology, Moscow, 2010, 33 p.
3. National Clinical Guidelines of the Higher School of
Economics, Moscow, 2009, 528 p.
4. Prevention of cardiovascular diseases in clinical practice. //
Russian Journal of Cardiology. – 2012. –№4, (96). – Appendix, 84 pages.
5. Solgalova S.A. Diagnosis and treatment of arterial hypertension
(in tables and diagrams): methodical manual / S. A. Solgalova, S. G.
Kechedzhieva, A. Ya. Sokhach // Stavropol: Publishing House of StGMA,
2012 - 23 p.
6. Rosei E.A. Treatment of complicated and uncomplicated
hypertensive crises / E.A.Rosei, M.Salvetti, C.Farsang

43