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 TREATMENT OF THE ARTERIAL HYPERTENSION
After the publication of different studies clinic is accepted in practice that the treatment of the hypertension goes so far as to reduce 40 % the cerebral vascular episodes and reduces in 14 % the coronary pathology.
For it it is suitable to treat the hypertension, but the results are relatively poor in the prevention of the cardiovascular diseases.
After new groups of medicines have interfered and these remarks have led to facing the treatment of the hypertension to a new concept based on a system more flexible than the previous one (staggered protocols).
At present more importance happens to not pharmacological treatments (exercise, decrease of the obesity, diets poor in salt) later to go on to the pharmacological treatment.
On having begun with the election of a medicine the selection, it becomes more individualized, there being less tendency to force the dose. If a medicine does not control the hypertension it changes to other or the second medicine is added. Even in hypertense light one tends to suspend the pharmacological treatment after a few years, supporting or increasing not pharmacological measurements.
In general the treatment must be restored when the average of the diastolic pressures for three or four months is equal or superior to 100 mm Hg.
If it is minor, to initiate a treatment, there must be other risk factors simultaneously, how it can be a cardiac injury (ventricular hypertrophy, renal insufficiency, etc) or other factors of risk (diabetes, familiar cardiovascular disease history).
It has to of trying to support the diastolic tension lower than 90 mm Hg, by means of a treatment that the patient tolerates well.
We must bear in mind in the treatment of the hypertense one that it is fundamental in the control of the cardiovascular disease they are going to influence also other factors that can be modified by these medicines:
- The diuretics (except the indapamida), increase the cholesterol and LDL without changing scarcely the HDL.
- The beta - bloqueantes (except the celiprolol), they diminish the HDL without modifying LDL or the entire cholesterol. The effect is so much major minor is the activity simpaticomimética intrinsic of the medicine.
- The diuretics tiazídicos cause intolerance to the glucose and increase of the resistance to the insulin. The same happens with the beta - bloqueantes, without there being sufficient information to establish differences between the medicines of the group.
- The alfabloqueantes (prazosina, doxazosina), are receiving lately certain attention because they modify favorably the relation HDL - LDL and the control of the glycemia.
- Not even the inhibiting ones of the angiotensina-convertasa, either the antagonists of the calcium or the majority of antihypertensive considered of the second election influence the fractions lipídicas not on the glycemia.
These appreciations are important because the relative absence of efficacy of the antihypertensive ones to prepare the cardiovascular diseases (14 %), entity has been interpreted as a proof that the metabolic actions have sufficiently to resist, partially, the beneficial effect of lowering the tension.
As normal rules we must bear in mind that:
- We must avoid the diuretics and beta - bloqueantes in the diabetics, using preferably inhibiting of the ACE or antagonists of the calcium.
- In dislipemias it does the same to itself but sometimes one resorts to the diuretics or beta - bloqueantes if it is going to suppose a progress in the control of the HTA or if they are indicated by another cause.
- If they do not exist the said risk factors they must use the most experienced (ancient) medicines and, in general, avoid the high doses of any of them and purify the possibilities of not pharmacological therapies.
THERAPEUTIC RULES OF THE TREATMENT OF THE HYPERTENSION
HANDLING OF THE HYPERTENSION
As the answer to almost all the antihypertensive medicines is flat, before picture of rebellious HTA, raising the dose of the medicines usually has effect small, for it one resorts to to the association of medicines.
ASSOCIATIONS OF ANTIHYPERTENSIVE USUAL
- Betabloqueante with
- IECA
- Calcioantagonista
- Diuretic
- IECA with
- Inhibitor adrenérgico
- Calcioantagonista
- Diuretic
- Calcioantagonista with
- IECA
- Inhibitor adrenérgico
- Calcioantagonista
- Diuretic with
- IECA
- Inhibitor adrenérgico
- Calcioantagonista
USUAL RULES
1er STEP
- Diuretics
- Beta - bloqueantes
- Inhibiting of ACE
- Antagonists of the calcium.
The group of the alfabloqueantes thinks nowadays with more attention for his favorable effects on the lipidograma and the glycemia.
2 ° STEP
- Diuretic + betabloqueante (Attention: it accumulates the actions of two components on the glycemia and the relation HDL / LDL).
- Diuretic + inhibitor of the ACE
- Other combinations of the pharmacological groups quoted in the previous step:
3er STEP
Two medicines of the previous step + hidralazina.
diuretic + betabloqueante + alfabloqueante (can be replaced successfully with diuretic + labetalol)...
4 ° STEP
- To try to replace one of the medicines of the triple therapy for minoxidilo.
- Diuretic + betabloqueante + ECA inhibitor + hidralazina (or with alfabloqueante, antagonist of the calcium, in replacement of one of the said ones).
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