Prehospital care for sudden increases in blood pressure and hypertensive crisis

Kapoten

When used simultaneously with immunosuppressants and cytostatics, the risk of developing leukopenia increases.

When used simultaneously with potassium-sparing diuretics (including spironolactone, triamterene, amiloride), potassium preparations, salt substitutes and dietary supplements containing potassium, hyperkalemia may develop (especially in patients with impaired renal function), because ACE inhibitors reduce the content of aldosterone, which leads to potassium retention in the body while limiting the excretion of potassium or its additional intake into the body.

With the simultaneous use of ACE inhibitors and NSAIDs, the risk of developing renal dysfunction increases; hyperkalemia is rarely observed.

When used simultaneously with loop diuretics or thiazide diuretics, severe arterial hypotension is possible, especially after taking the first dose of the diuretic, apparently due to hypovolemia, which leads to a transient increase in the antihypertensive effect of captopril. There is a risk of developing hypokalemia. Increased risk of developing renal dysfunction.

When used simultaneously with anesthetics, severe arterial hypotension is possible.

When used simultaneously with azathioprine, anemia may develop, which is due to inhibition of erythropoietin activity under the influence of ACE inhibitors and azathioprine. Cases of the development of leukopenia have been described, which may be associated with additive suppression of bone marrow function.

When used simultaneously with allopurinol, the risk of developing hematological disorders increases; Cases of severe hypersensitivity reactions, including Stevens-Johnson syndrome, have been described.

With the simultaneous use of aluminum hydroxide, magnesium hydroxide, magnesium carbonate, the bioavailability of captopril decreases.

Acetylsalicylic acid in high doses may reduce the antihypertensive effect of captopril. It has not been conclusively established whether acetylsalicylic acid reduces the therapeutic effectiveness of ACE inhibitors in patients with coronary artery disease and heart failure. The nature of this interaction depends on the course of the disease. Acetylsalicylic acid, by inhibiting COX and prostaglandin synthesis, can cause vasoconstriction, which leads to a decrease in cardiac output and worsening of the condition of patients with heart failure receiving ACE inhibitors.

There are reports of increased plasma concentrations of digoxin when captopril is administered concomitantly with digoxin. The risk of drug interactions is increased in patients with impaired renal function.

When used simultaneously with indomethacin and ibuprofen, the antihypertensive effect of captopril decreases, apparently due to inhibition of prostaglandin synthesis under the influence of NSAIDs (which are believed to play a role in the development of the hypotensive effect of ACE inhibitors).

When used simultaneously with insulins, hypoglycemic agents and sulfonylurea derivatives, hypoglycemia may develop due to increased glucose tolerance.

With simultaneous use of ACE inhibitors and interleukin-3, there is a risk of developing arterial hypotension.

When used simultaneously with interferon alpha-2a or interferon beta, cases of severe granulocytopenia have been described.

When switching from clonidine to captopril, the antihypertensive effect of the latter develops gradually. If clonidine is suddenly discontinued in patients receiving captopril, a sharp increase in blood pressure may occur.

With simultaneous use of lithium carbonate, the concentration of lithium in the blood serum increases, accompanied by symptoms of intoxication.

When used simultaneously with minoxidil and sodium nitroprusside, the antihypertensive effect is enhanced.

When used simultaneously with orlistat, the effectiveness of captopril may decrease, which can lead to increased blood pressure, hypertensive crisis, and a case of cerebral hemorrhage has been described.

With simultaneous use of ACE inhibitors with pergolide, the antihypertensive effect may be enhanced.

When used simultaneously with probenecid, the renal clearance of captopril is reduced.

When used simultaneously with procainamide, the risk of developing leukopenia may increase.

When used simultaneously with trimethoprim, there is a risk of developing hyperkalemia, especially in patients with impaired renal function.

When used simultaneously with chlorpromazine, there is a risk of developing orthostatic hypotension.

When used simultaneously with cyclosporine, there are reports of the development of acute renal failure and oliguria.

It is believed that the effectiveness of antihypertensive drugs may be reduced when used simultaneously with erythropoietins.

CAPOTENE (tablets)

This is not necessary, but first you need to reduce the load on the walls of blood vessels.
Quite often, people around me say that high blood pressure is normal for them, and the body has already adjusted to such pressure. However, doctors fundamentally disagree with such statements; the vessels cannot be loaded in this way. Many feel an increase in blood pressure, but some do not, then modern gadgets, such as fitness bracelets, which can monitor the condition of its owner, can come to the rescue...

There are situations in life when the pressure rises sharply and needs to be reduced sharply; for such situations, you can use pills.”

However, you need to understand that the pressure will drop sharply, but after a while it will rise again. Capoten will quickly cope with blood pressure, but will not keep it normal; for this you need to use other medications, for example, the diuretic Indapamide, I wrote a review.

Let's see what Capoten's tablet looks like

There are drawings on it, according to which it can be easily broken into pieces. The tablet can be broken into two or four pieces and drunk, for example, a quarter; this may be necessary when you need to lower the pressure by not very large values. You should know that the tablet is very strong, and I personally do not recommend taking a whole tablet if the pressure is below one hundred and eighty. The drug has enough side effects, I won’t post all the instructions.

Capoten should be taken by dissolving it under the tongue. I can’t say that the tablet is tasty, but it is quite edible.

Personally, I always have a Kapoten plate with me in my bag, although I myself have not taken it for more than a year, there is no such need, to my great joy. However, the plate gradually becomes empty, colleagues and friends sometimes need pills... I have also mastered the method of reducing blood pressure through proper breathing. I wrote in detail about how to breathe in a review about Indapamide (I gave a link to this drug above), but just in case I’ll write it here too.

Inhale slowly through your nose (and with your stomach), then hold your breath for about three to five seconds, and slowly exhale through your mouth (again with your stomach) and again hold your breath for three to five seconds. Repeat several times. It really works, you just need to learn to breathe correctly. It's not very difficult. Later I learned that this breathing method allows you to quickly calm down. But CAUTION: breathing this way can make you dizzy. The shelf life of the tablets is quite long, and is indicated on each plate and the box itself.

It does not require special storage conditions, so you can keep it in your purse.

I recommend this drug only as an emergency aid to lower blood pressure in critical cases. Thank you all for your attention!

Rational combinations of antihypertensive drugs

Lecture transcript

XXVI All-Russian Educational Internet Session for doctors
Total duration: 20:10

Oksana Mikhailovna Drapkina, executive director of the Internet Session, secretary of the interdepartmental council on therapy of the Russian Academy of Medical Sciences: - It is with great pleasure that I give the floor to Professor Maria Genrikhovna Glezer. "Rational combinations of antihypertensive drugs"

00:10

Glezer Maria Genrikhovna, Doctor of Medical Sciences:

– Dear colleagues. Arterial hypertension is currently the No. 1 risk factor. In 2010, it was recognized by the World Health Organization as the No. 1 killer. It is high blood pressure that determines more than 50% of all cases of coronary heart disease and strokes.

What are the classes of drugs for long-term treatment of arterial hypertension. 8 classes. But we must first use the first 5 classes:

• diuretics;
• beta blockers;
• ACE inhibitors;
• sartans;
• calcium channel blockers.

Alone or in combination, these drugs are used to reduce the risk of complications.

There is a sufficient evidence base for these first five drugs. These classes of drugs may reduce cardiovascular morbidity and death.

What are the main pathophysiological mechanisms involved in increased blood pressure?

This is the activation of the renin-angiotensin system. Activation of the sympathetic nervous system. Increase in circulating blood volumes (changes in water and electrolyte balance).

Ultimately, these systems will lead to changes in intracellular calcium transport. The drugs that we have affect different stages of pathogenesis.

Beta blockers, sympatholytics, imidazoline receptor agonists - for increased activity of the sympathetic nervous system. Diuretics – for increased circulating blood volume, lipid metabolism disorders. Calcium antagonists – to change intracellular calcium transport. 3 groups of drugs (inhibitors, sartans and direct renin inhibitors) - on the activated rhinin-angiotensin system.

We know well from clinical practice that all patients with arterial hypertension are different. The contribution of each pathogenetic mechanism may vary from person to person. For some, an increase in circulating blood volume prevails. Some people have predominantly increased activity of the renin-angiotensin system. Some people (especially young people) experience an increase in the activity of the sympathetic nervous system.

It is clear that it is most often impossible to solve the problem with one class of drugs.

02:34

Athena Study.

More than 2,000 women in the Russian Federation were analyzed. Where hypertension was controlled, 2-component, 3-component or more drugs were more often used to treat high blood pressure.

Where there was no control (in fact, this was the majority), either these patients were not treated at all, or monotherapy was used. This is further evidence that different classes of drugs need to be combined in order to achieve blood pressure goals.

Categories of patients most likely to require combination therapy:

• persons who have a significant increase in blood pressure (above 160/100 mm Hg);
• patients with diabetes mellitus (DM);
• people who have certain lesions of organ systems. For example, kidney damage;
• left ventricular hypertrophy (LVH);
• people who smoke, are obese, have sleep disordered breathing.

Combination therapy is the key to success in achieving the goal (based on the pathogenetic mechanisms that I have already mentioned and the complications that often occur in patients).

What do we call a goal? The best evidence to date is that the goal is to achieve target blood pressure values.

In September 2010, there were some changes to the target values. Now, regardless of the degree of risk, they try to keep the pressure below 140 and 130. Up to 140 mm Hg. Art. systolic and 90 – 80 mm Hg. Art. by diastolic.

Not a single large study (probably how they were structured) has proven that a decrease of less than 130 and 80 mm Hg. Art. provides an additional reduction in morbidity and mortality. At the same time, a decrease from 130 is a very difficult moment, requiring a lot of effort and financial costs.

In persons over 80 years of age, based on data from the HYVET study, target values ​​for systolic pressure are set at less than 150 mmHg. Art. Low numbers remain with significant proteinuria.

05:04

A meta-analysis of 147 studies in older people aged 60–69 years showed that while one standard-dose drug reduces the risk of coronary heart disease by 25% and stroke by 35%, then a combination of three drugs at half the dosage reduces the risk of developing both coronary heart disease and stroke is almost twice as high.

A very interesting analysis was published in 2009. A 2-drug combination has been shown to be 5 times more effective in lowering systolic blood pressure (SBP) than doubling the dose of either drug class. Be it beta blockers, diuretics, inhibitors, calcium antagonists. This is proof that it is combination therapy that allows you to achieve the desired values.

In addition, combination therapy can undoubtedly lead to a faster, more pronounced reduction in blood pressure.

The VALUE study clearly showed: if during the first month from the start of treatment the pressure decreases by more than 10 mm Hg. Art., then the number of fatal/non-fatal cardiovascular events, strokes and death from all causes becomes significantly less than in those people who did not achieve a reduction during the first month.

06:29

The second point that you should pay attention to: you should still strive to achieve the target numbers within 6 months. This is less than 140 mmHg. Art. Then all outcomes, including fatal events, heart attacks, strokes, deaths from all causes, and hospitalization will be significantly lower.

In my opinion, how should the decision-making process proceed when treating patients with arterial hypertension.

Certainly. We can start with monotherapy. This ensures the safety of treatment for our patients. If you see a person for the first time and you do not know what the reaction will be to antihypertensive therapy, you can start with monotherapy.

But you don’t need to go further in this vicious circle: you reached the maximum increase in dose, you became convinced that it was ineffective, you changed the drug, and so on. Patients stop this treatment, they leave the doctor.

Correct decision-making process: Tried monotherapy. We realized that it was quite effective and safe, and switched to combination therapy. We are moving further along the path of increasing doses of combination drugs. This is the principle I preach.

Plus one: the patient came - the treatment was not effective enough - the next class of drugs was added. If something else doesn’t suit you, the next class is added. Then you will be more likely to succeed.

When it comes to combination therapy, they always say: “This is polypharmacy, it is bad for patients, and so on.” Correct, because combination therapy must undoubtedly be rational.

What is rational therapy? This is when the effectiveness of treatment increases, while the incidence of side effects decreases.

This can lead to an increase in efficiency. We use different classes of drugs, influence different parts of the pathogenesis of the disease and eliminate the activation of counter-regulatory systems. If you use drugs in smaller dosages, then dose-related side effects may, of course, be reduced.

The side effects of one of the components can be eliminated by using another component.

08:51

Recommended combinations of drugs for hypertension.

Diuretics plus inhibitors or sartans. Best time to use: Where there is a high risk of heart failure.

Beta blockers and dihydropyridine calcium antagonists. When is it best to use: for ischemic heart disease.

Metabolically neutral class of drugs, sartan inhibitors, calcium antagonists. In persons at high metabolic risk.

Today, this is probably how one can imagine rational combinations. It's a diuretic plus something. Anything – these are inhibitors or sartans.

Another type of combination. Calcium antagonists plus ACE inhibitor or calcium antagonists plus sartans. Dihydropyridine calcium antagonists are used with beta blockers in patients with coronary artery disease.

Currently, the combination of diuretics plus calcium antagonists is considered irrational because this combination almost doubles the risk of myocardial infarction. Diuretics plus beta blockers had the best effect in this case.

The final picture looks like this: 1) calcium antagonists plus inhibitors or sartans and 2) diuretics, inhibitors and sartans.

The slide shows the recommended combinations of antihypertensive drugs in a trapezoid.

This trapezoid is considered the most rational today.

I took the liberty of slightly modifying the picture shown in the European recommendations. I drew a triangle. At the top I put a group of drugs that inhibit the activity of the renin-angiotensin system (RAS) plus diuretics or plus calcium antagonists. Or the three of us together in the center of the class. There will be effective treatment.

What is the rationale for saying that a combination of diuretics, inhibitors or sartans is an effective and rational combination. It is known that diuretics and inhibitors (sartans) are powerful antihypertensive drugs with pronounced organoprotective properties that can reduce the incidence of morbidity and mortality in arterial hypertension (AH).

The enhancement of the hypotensive effect is due to the fact that conditions are created for the most pronounced action of both components. The activation of counter-regulatory mechanisms is eliminated: diuretics reduce sodium levels, thereby stimulating the production of renin. This leads to a more pronounced antihypertensive effect of drugs that inhibit the activity of the angiotensin system.

At the same time, inhibitors or sartans, by reducing the production of aldosterone, reduce the excretion of potassium from the body, which is always not good when prescribing diuretics. In addition, inhibitors and sartans have a beneficial effect on purine metabolism and reduce the severity of hyperuricemia.

11:50

The combination with diuretics allows you to achieve the same reduction in blood pressure 4 weeks earlier compared to monotherapy with any of the drugs. This leads to the fact that better treatment results can be achieved.

ACE inhibitors (in general, probably the same with sartans) are drugs with pronounced organotensive properties. They influence vascular remodeling, reducing or normalizing the ratio between the lumen of blood vessels and the intima-media complex. This is very important for persistently maintaining blood pressure at normal levels and avoiding crises. The data are given for one of the long-acting ACE inhibitors - the drug Lisinopril. In our country it is often used in the form of the drug “Diroton”. Normalization of the vascular ratio in arterial hypertension.

Indicators related to heart function improve. In particular, improving the diastolic function of the heart. The ratio of peak E to peak A returns to almost normal. The time of isovolumic relaxation improves, the diameter of cardiomyocytes decreases. It is very important that myocardial fibrosis is reduced in patients with arterial hypertension. This is one of the first steps to developing a particular form of heart failure. Heart failure, which is caused by hypertension with preserved ejection fraction.

13:27

ACE inhibitors are known to work very well in obesity because the activity of the renin-angiotensin system is increased in obesity. Each fat cell produces the angiotensin gene in an amount equal to 70 liver cells.

One of the first studies that was conducted demonstrated that lisinopril was effective in approximately 60 patients. Hydrochlorothiazide (HTC) is less effective. The most important thing is that this effect is detected at doses of “Lisinopril” of 10 mg, and “Hydrochlorothiazide” - 50 mg. The side effects of Hydrochlorothiazide may already be quite pronounced.

A very interesting study was conducted in Russia - the Desire study. This study showed that the use of lisinopril can normalize the abnormal daily blood pressure profile. In particular, Lisinopril in women halved the night-picker type when there is a sharp increase in blood pressure at night.

Another achievement that was shown in this study. The use of the drug in the evening allows to normalize blood pressure to a greater extent and reduce the disturbed profile. This is important because night-pickers have a higher incidence of strokes, adverse events, and so on.

Combination with diuretics. Diuretics are one of the most important classes of drugs for the treatment of arterial hypertension. Returning to the Athena study, I would like to say that the difference is in the prescription of drugs where it was ineffective: diuretics were used less often. All other classes were used approximately equally. If diuretics are not prescribed, then it is even difficult to say that something is effective or ineffective.

15:22

Two studies: UKPDS and LIFE. In the UKPDS study, the target blood pressure was 160/90 mmHg. Art. 60% of patients were already on diuretics. In the LIFE study, where the target numbers were 140/90 mmHg. Art. 90% of patients required diuretics.

In our country, the use of diuretics is somewhere around 30%. This is not a sufficient purpose. According to the LIFE study, people who received diuretic drugs had a 30-40% lower risk of various adverse events (cardiovascular death, heart attack, stroke), and a 45% lower overall mortality rate. This is a very important class of drugs that should be used in combination therapy.

I'll say it again. We can say that hypertension is resistant to treatment if a combination of three antihypertensive drugs prescribed in adequate dosages does not reduce blood pressure, but one of these drugs is a diuretic. Thus, this is a very important way to achieve target blood pressure values.

The use of ready-made combination forms is an easier path to success in treating patients with arterial hypertension.

Where hypertension was controlled, a higher percentage of cases used preformed combination dosage forms than in groups where there was no sufficient effect.

I want to show you one more study. Where a combination of Lisinopril and Hydrochlorothiazide was used (in our country, the drug Co-Diroton), patient adherence to treatment was higher than when Lisinopril and Hydrochlorothiazide were used in 2- x different tablets.

The creation of finished dosage forms follows the path of rational combinations, that is, a diuretic plus an ACE inhibitor, or a diuretic plus sartan. Or a combination based on calcium antagonists, to which inhibitors, sartans or beta blockers are added in the treatment of patients with coronary heart disease.

Now a drug has been released that contains a combination of 3 groups. This is Amlodipine plus Valsartan plus Hydrochlorothiazide. This is the right direction: when you have selected certain dosages, then you can already use ready-made combined forms.

In a nutshell about the combination of calcium antagonists with inhibitors or sartans. Calcium antagonists are good at reducing the risk of stroke, inhibitors are good at reducing the risk of myocardial infarction. This provides a reduction in the risk of major cardiovascular events.

18:14

Advantages and disadvantages of mono- and combination therapy for arterial hypertension.

Of course, if you use combination therapy, there is always a higher response rate. This is a very high possibility of dose titration, because you can take a quarter of a tablet from one package, a full tablet from another, and so on. The incidence of side effects is lower if we use rational combinations.

But it becomes difficult to accept. Patients with hypertension will not use anything that is complicated. As soon as the necessary dosages have been selected, you need to switch to fixed combinations, which has an advantage in absolutely all positions.

In conclusion, I want to say what rational combination antihypertensive therapy is. This is an impact on different parts of the pathogenesis of hypertension and elimination of the activation of counter-regulatory mechanisms. Based on this, the effectiveness of treatment increases. When it is effective, people will be more committed (commitment increases).

A good combination is a decrease in the frequency of side effects - which means an increase in adherence. Increasing adherence means increasing the effectiveness of treatment.

Let's look at the second part of this circle. Increasing efficiency, increasing adherence means decreasing cost. Any change in therapy entails, of course, an increase in the cost of treatment. And when it’s not so expensive, people will be more committed. They will better follow the doctor's orders. You should always think about this.

Thank you for your attention.

Oksana Drapkina: Thank you very much, Maria Genrikhovna.