#1
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Àðòåðèàëüíàÿ ãèïåðòîíèÿ. Ýòî èíòåðåñíî.
Óâàæàåìûå êîëëåãè! Â ðàìêàõ òåìû ïðåäëàãàþ ïóáëèêîâàòü è îáñóæäàòü èíòåðåñíûå ñîáûòèÿ èç ìèðà ÀÃ.
Marvin Moser. Resistant or Difficult-to-Control Hypertension. N Engl J Med 2006;355:385-92. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] "This article focuses on the evaluation and management of resistant hypertension as well as difficult-to-control hypertension, which is defined here as persistently elevated blood pressure despite treatment with two or three drugs but not meeting the above-mentioned strict criteria for resistant hypertension." Âîïðîñû äëÿ îáñóæäåíèÿ: 1. Êàê ÷àñòî â Âàøåé ïðàêòèêå âñòðå÷àåòñÿ ðåçèñòåíòíàÿ ÀÃ? 2. Âàøà "ëþáèìàÿ" (íàèáîëåå ýôôåêòèâíàÿ) êîìáèíàöèÿ èç ãèïîòåíçèâíûõ ïðåïàðàòîâ? ×àñòî ëè ïðèìåíÿåòå âåðîøïèðîí? |
#2
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Ëå÷åíèå ïðåäãèïåðòîíèè (ÃÁ I ñòàäèè)
Stevo Julius. Feasibility of Treating Prehypertension with an Angiotensin-Receptor Blocker. Trial of Preventing Hypertension (TROPHY) Study. N Engl J Med 2006;354. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
"Conclusions: Over a period of four years, stage 1 hypertension developed in nearly two thirds of patients with untreated prehypertension (the placebo group). Treatment of prehypertension with candesartan appeared to be well tolerated and reduced the risk of incident hypertension during the study period. Thus, treatment of prehypertension appears to be feasible." Èçâåñòíî, ÷òî ïàöèåíòû ñ ýïèçîäè÷åñêèìè ïîäú¸ìàìè ÀÄ èìåþò áîëüøèé øàíñ ðàçâèòèÿ ÀÃ.  ïðåäñòàâëåííîé ðàáîòå ëå÷åíèå ÀÐÀ â òå÷åíèå 3 ëåò äîñòîâåðíî ïðåäîòâðàùàëî ðàçâèòèå ñòîéêîé ÀÃ. Íåèçâåñòíî, âëèÿåò ëè íà æåñòêèå êîíå÷íûå òî÷êè ëå÷åíèå òàêèõ ïàöèåíòîâ. 1. Ýôôåêòèâíîñòü íåìåäèêàìåíòîçíîãî ëå÷åíèÿ òðàíçèòîðíîé Àà íåâûñîêàÿ. Íå áóäåò ëè ïðîùå äëÿ ïàöèåíòà/äîêòîðà ñðàçó âðó÷èòü áåçîïàñíûé/ýôôåêòèâíûé ïðåïàðàò äëÿ ïðåäîòâðàùåíèÿ ÀÃ? Ñêîëüêî ïàöèåíòîâ ìû áóäåì "ïåðåëå÷èâàòü"? 2. Ñêîëüêî âðåìåíè ñëåäóåò îöåíèâàòü âëèÿíèå íåìèäèêàìåíòîçíîãî ëå÷åíèÿ? Êàê ÷àñòî â Âàøåé ïðàêòèêå ìîäèôèêàöèÿ îáðàçà æèçíè ïðèâîäèëà ê ñíèæåíèþ ÀÄ? |
#3
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European Society of Hypertension
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] American Society of Hypertension [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#4
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Öèòàòà:
Öèòàòà:
Ïðè èõ ñîáëþäåíèè,ôðàçà Öèòàòà:
Ýòî ìîæåò áûòü òîãäà,êîãäà íåìåäèêàìåíòîçíîå ëå÷åíèå,íàçíà÷àåòñÿ â ñëó÷àÿõ,îáÿçûâàþùèõ /îïÿòü æå ñîãëàñíî êðèòåðèåâ/ òàêîâîå íà÷àòü. 2-íåìåäèêàìåíòîçíîå ëå÷åíèå,à èìåííî èçìåíåíèå æèçíåííûõ ïðèâû÷åê-îòêàç îò êóðåíèÿ,èçìåíåíèå ðåæèìà ïèòàíèÿ,óâåëè÷åíèå ôèçè÷åñêîé íàãðóçêè/õîäüáà åæåäíåâíî íå ìåíå 30-40 ìèíóò/,íàçíà÷àåòñÿ íà 3 ìåñÿöà.
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doctor Ðolonsky israel Ñíèìêè ñìîòðþ òîëüêî â ïðÿìîì ïîêàçå.,áåç íåîáõîäèìîñòè ñêà÷èâàíèÿ. Ïðîñüáà ïîêàçûâàòü ñíèìêè â ïðàâèëüíîì ïîëîæåíèè. |
#5
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Öèòàòà:
2) Êî-ðåíèòåê + ëàöèäèïèí èëè (ìåíåå ëþáèìûé) àìëîäèïèí + åñëè íàäî, áèñîïðîëîë. Âîîáùå, "êîðåíü òðàâû ðåíèòåê", êàê åãî íàçûâàëà îäíà ñòàðóøêà, ¹1 â ìîåì ðåéòèíãå. Âåðîøïèðîí â öåëÿõ ñíèæåíèÿ ÀÄ - êðàéíå ðåäêî (ñïàñèáî çà ñòàòüþ, áóäó çíàòü). Ñîáñòâåííî, ñ âåðîøïèðîíîì ìîãó âñïîìíèòü òîëüêî îäíó äàìó, ïî âñåé âèäèìîñòè, ñ ñ-ìîì Êîííà. |
#6
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doctor Ðolonsky israel Ñíèìêè ñìîòðþ òîëüêî â ïðÿìîì ïîêàçå.,áåç íåîáõîäèìîñòè ñêà÷èâàíèÿ. Ïðîñüáà ïîêàçûâàòü ñíèìêè â ïðàâèëüíîì ïîëîæåíèè. |
#7
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Î íåñîñòîÿòåëüíîñòè íåìåäèêàìåíòîçíûõ ìåòîäîâ ñíèæåíèÿ ÀÄ
1. Ñíèæåíèå âåñà "Ëå÷åíèå, íàïðàâëåííîå íà äëèòåëüíîå ñíèæåíèå âåñà â áîëüøèíñòâå ñëó÷àåâ íåýôôåêòèâíî è 90-95% ïàöèåíòîâ â ïîñëåäñòâèè âîîñòàíàâëèâàþò ñâîé âåñ [1, 2]" [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] 1. Wadden TA. Treatment of obesity by moderate and severe caloric restriction: results of clinical research trials. Ann Intern Med 1993;229:688-693. 2. Rosenbaum M, Leibel RL. Pathophysiology of childhood obesity. Adv Pediatr 1988;35:73-137 2. Îòêàç îò êóðåíèÿ "In 2004, an estimated 14.6 million (40.5%) adult smokers had stopped smoking for at least 1 day because they were trying to quit; however, about 5% are successful in quitting for at least 1 year. [1, 2]" [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] 1. Centers for Disease Control and Prevention. Smoking cessation during previous year among adults – United States, 1990 and 1991. MMWR Morb Mortal Wkly Rep 1993; 42: 504–507. 2. Centers for Disease Control and Prevention. Cigarette smoking among adults, United States 2002. MMWR Morb Mortal Wkly Rep 2004; 53: 427–431 |
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#8
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Öèòàòà:
À íàñ÷åò ñíèæåíèÿ êàëîðèéíîñòè ïèòàíèÿ è ïðî÷åãî ÁÅÇ èçìåíåíèÿ ìîòèâàöèè, ïðèâîäÿùåé ê îáæîðñòâó-îæèðåíèþ, ÿ â äðóãîé òåìå îòâå÷àëà. Ýòî ñèìïòîìàòè÷åñêàÿ òåðàïèÿ. È ýôôåêòèâíîñòü ñîîòâåòñòâóþùàÿ. Ó íàñ åñòü ÷óäåñíàÿ ìîäåëü. "Òðè íî÷íûõ ñåàíñà ïñèõîòåðàïèè". Ýôôåêò ïîòðÿñàþùèé, íî äëèòñÿ ìàêñèìóì ãîäà 1,5 - 2, à ïîòîì íàäî ñíîâà ïðîõîäèòü "îáðàáîòêó", èíà÷å âåñ ïîëçåò îáðàòíî.
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Lead, follow, or get out of the way. — Thomas Paine |
#9
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Öèòàòà:
2. àòåíîëîë, ãèïîòèàçèä, ðåòàðäíûé íèôåäèïèí è ëþáîé èíãèáèòîð êðîìå êàïòî è ïåðèíäî (âàðèàöèè ïî ñèòóàöèè). Äåøåâî è íåñåðäèòî. Âåðîøïèðîí ïî÷òè íèêîãäà. |
#10
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Öèòàòà:
2. ×àùå ñòàðò ñ ÈÀÏÔ(ýíàëàïðèë, ëèçèíîïðèë, êâèíàïðèë)+ÃÕÒÇ, äàëüøå ÁÀÁ ("ëþáèìûé" ìåòîïðîëîë) +- ÀÊ ("ëþáèìûé" àìëîäèïèí). Ïÿòûé ïðåïàðàò - äîêñàçîçèí / ìîêñîíèäèí. Âåðîøïèðîí - ïðè ïåðâè÷íîì ãèïåðàëüäîñòåðîíèçìå. Êîòîðûé (ó ìåíÿ) òîæå íåðåäêî áûâàåò â ñèëó ñïåöèôèêè ïðîèçâîäñòâà. |
#11
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Á-ÀÁ èñêëþ÷åíû èç UK ðåêîìåíäàöèé ïî íà÷àëüíîé òåðàïèè ïàöèåíòîâ ñ Àà [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
"The GDG stated that beta blockers were usually less effective in the head-to-head trials in reducing cardiovascular events, particularly stroke. Further, because most of these trials used atenolol and because of the limited data with another beta blocker, it is unclear whether this is a drug class effect or a specific dug effect. However, they note that if the data with atenolol studies are excluded, the “total evidence on the use of beta blockers for the treatment of hypertension is much less than for the other main drug classes.”Thus, beta blockers should not be used as initial therapy, unless there is a compelling indication. The GDG also stated that good studies with beta blockers other than atenolol are needed. Further, concerns about the increased risk of new-onset diabetes related to beta blockers also factored into their excluding the use of beta blockers, except for compelling indications." |
#12
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Ê âîïðîñó î êîìïëàåíñå
Ïàöèåíòà ñ õðîíè÷åñêèì çàáîëåâàíèåì (íàïðèìåð, ÀÃ) íå òîëüêî òðóäíî ìîòèâèðîâàòü íà èçìåíåíèå îáðàçà æèçíè, íî è î÷åíü, î÷åíü òÿæåëî óáåäèòü ïîñòîÿííî ïðèíèìàòü ëåêàðñòâà. Èíòåðåñíàÿ ñòàòüÿ î "òðóäíîì" ïàöèåíòå, áåç ñîìíåíèÿ çàñëóæèâàþùàÿ âíèìàíèÿ.
1. Alison C. Essary. How to make the “difficult” patient encounter less difficult. JAAPA VOL.18, NO. 5 MAY 2005 [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] "This article reviews four types of "difficult" patient encounters that might well end badly. Each scenario is followed by communication techniques that PAs can use to improve the outcome." 2. Lars Osterberg. Adherence to Medication. N Engl J Med 2005;353:487-97.[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] "Drugs don’t work in patients who don’t take them. — C. Everett Koop, M.D." |
#13
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 ìîåé ïðàêòèêå ðåçèñòåíòíàÿ Àà âñòðå÷àåòñÿ î÷åíü ÷àñòî (ïîëèìîðáèäíûå ïîæèëûå áîëüíûå ñ ÑÄ 2 òèïà). Äàæå ïðè óñëîâèè àêêóðàòíîãî ðåãóëÿðíîãî ïðèåìà ïðåïàðàòîâ (ñ ìîäèôèêàöèåé îáðàçà æèçíè çàâñåãäà ïðîáëåìû ó òàêèõ áàáóøåê, íî ïûòàåìñÿ).
Êîìáèíàöèÿ çàâèñèò îò áóêåòà ñîïóòñòâóþùèõ ïàòîëîãèé, íî îáû÷íî âêëþ÷àåò èíãèáèòîð+ãèïîòèàçèä, àìëîäèïèí, áåòà-áëîêåð. Âåðîøïèðîí - òîæå ðåäêî.
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
#14
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Ðåçèñòåíòíóþ ÀÃ âèæó ïðè îòñóòñòâèè êîìïëàåíñà, à òàêîå íàáëþäàåòñÿ, óâû, íåðåäêî.
 äåëî èäóò ÈÀÏÔ (÷àùå ÷òî òî èç ýíàëàïðèëà, íî ìîæåò è ðàìè-, è ëèçèíî-), äèóðåòèê (÷àùå èíäàïàìèä), ïðîëîíãèðîâàííûé äèãèäðîïèðèäèíîâûé àíòàãîíèñò Ñà è áåòà-áëîêåð - ïî÷òè îáÿçàòåëüíî, ïîñêîëüêó áîëüøèíñòâî ãèïåðòîíèêîâ ñ ÈÁÑîì. Âîîáùå, ÀÃ, åñëè îíà íå ñèìïòîìàòè÷åñêàÿ, äëÿ ñòàöëå÷åíèÿ - áîëÿ÷êà î÷åíü áëàãîäàðíàÿ. Âîò óäåðæàòü ïîëó÷åííûé ýôôåêò íà àìáóëàòîðíîì ýòàïå - çàäà÷êà ïîñëîæíåå. |
#15
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Approach to Resistant Hypertension
I. Definition
Calhoun DA, Zaman MA, Nishizaka MK. Resistant hypertension. Curr Hypertension Reports. 2002; 4:221-228. Townsend RR. Refractory or resistant hypertension. J Clin Hypertension. 2002; 4:61. II. Prevalence Cuspidi C, Macca G, Sampieri L, et al. High prevalence of cardiac and extracardiac target organ damage in refractory hypertension. J Hypertension. 2001; 19:2063-2070. Hajjar I, Kotchen TA: Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 2003; 290:199-206. Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med. 2001; 345:479-486. III. Causes Calhoun DA, Nishizaka MK, Zaman MA, Thakkar RB, Weissmann P. Hyperaldosteronism among black and white subjects with resistant hypertension. Hypertension. 2002; 40:892-896. Conlin PR, Gerth WC, Fox J, et al. Four-year persistence patterns among patients initiating therapy with the angiotensin II receptor antagonist losartan versus other antihypertensive drug classes. Clin Ther. 2001; 23:1999–2010. Davies SJ, Jackson PR, Ramsay LE, Ghahramani P. Drug intolerance due to nonspecific adverse effects related to psychiatric morbidity in hypertensive patients. Arch Intern Med. 2003; 163:592-600. Lim PO, Jung RT, MacDonald TM. Is aldosterone the missing link in refractory hypertension? Aldosterone-to-renin ratio as a marker of inappropriate aldosterone activity. J Human Hypertension. 2002; 16:153-158. Logan AG, Perlikowski SM, Mente A, et al. High prevalence of unrecognized sleep apnea in drug-resistant hypertension. J Hypertens. 2001;19:2271-2277. Martell N, Rodriguez-Cerrillo M, Grobbee DE, et al. High prevalence of secondary hypertension and insulin resistance in patients with refractory hypertension. Blood Pressure, 2003; 12:149-154. Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001; 135:825-834. Siegel D, Lopez J, Meier J. Cunningham F. Changes in the pharmacologic treatment of hypertension in the Department of Veterans Affairs 1997-1999: Decreased use of calcium antagonists and increased use of beta-blockers and thiazide diuretics. Am J Hypertension. 2001; 14:957-962. Vidt DG. Contributing factors in resistant hypertension: Truly refractory disease is rarely found in a properly conducted workup. Postgrad Med. 2000 (May 1); 107:57-70. Vidt DG. Pathogenesis and treatment of resistant hypertension. Minerva Medica. 2003; 94:201- 214. IV: Evaluation and Therapy Brown MJ, Cruickshank JK, Dominiczak AF, et al. Better blood pressure control: How to combine drugs. J Human Hypertension. 2003; 17:81-86. Brown MA, Buddle ML, Martin A. Is resistant hypertension really resistant? Am J Hypertension. 2001; 14:1263-1269. Burnier M, Schneider MP, Chiolero A, Stubi CL, Brunner HR. Electronic compliance monitoring in resistant hypertension: The basis for rational therapeutic decisions. J Hypertens. 2001; 19:335-341. Graves JW. Management of difficult-to-control hypertension. Mayo Clin Proc. 2000; 75:278-284. Muxfeldt ES, Bloch KV, Nogueira AR, Salles GF. Twenty- four hour ambulatory blood pressure monitoring pattern of resistant hypertension. Blood Pressure Monitoring. 2003; 8:181-185. Nishizaka MK, Zaman MA, Calhoun DA. Efficacy of low-dose spironolactone in subjects with resistant hypertension. Am J Hypertension. 2003; 16:925-930. Ouzan J, Perault C, Lincoff AM, Carre E, Mertes M. The role of spironolactone in the treatment of patients with refractory hypertension. Am J Hypertension. 2002; 15:333-339. Ram CV. Management of refractory hypertension. Am J Therapeutics. 2003; 10:122-126. Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Systematic review of randomized clinical trials. Arch Intern Med. 2004; 164:722-732. Singer GM, Izhar M, Black HR. Guidelines for hypertension: Are quality-assurance measures on target? Hypertension. 2004; 43:198-202. Taler SJ, Textor SC, Augustine JE. Resistant hypertension: comparing hemodynamic management to specialist care. Hypertension. 2002; 39:982-988. Urquhart J. Some economic consequences of non-compliance. Current Hypertension Reports. 2001; 3:473-480. Viskoper R, Shapira I, Priluck R, et al. Nonpharmacologic treatment of resistant hypertensives by device-guided slow breathing exercises. Am J. Hypertension. 2003; 16:484-487. Vlase H, Panagopoulos, Michelis M. Effectiveness of furosemide in uncontrolled hypertension in the elderly: role of renin profiling. Am J Hypetens. 2003; 16:187-193. |