Antihypertensive therapy. The right combination

All international recommendations emphasize that at a certain stage of treatment of hypertension, one drug becomes insufficient for adequate control of blood pressure. However, there is a significant question: in what clinical situations it is advisable to start with monotherapy, and in what follows, without exchanging small things,immediately appoint a combined antihypertensive therapy? In general, the following concepts are traced in the manuals: the higher the figures of blood pressure at the time of diagnosis and the more concomitant risk factors, the more justified the purpose of combination therapy from the very beginning of treatment. In this case, one should adhere to the least aggressive strategies, gradually increasing the dosage and adding additional drugs only in case of obvious necessity (see the diagram).

The second most important issue is, of course, the choice of specific drugs. Not all antihypertensive drugs are combined with each other. Thoughtless addition of drugs from alternative classes is unacceptable and can lead to dangerous consequences for the health of the patient. For example, the combination of non-dihydropyridine calcium blockers and beta-blockers is likely to result in a bradycardia or atrioventricular blockade. Another example: the combination of alpha-adrenoblockers with myotropic antihypertensive agents (eg, hydralazine) can lead to severe reflex tachyarrhythmia.

Thiazide diuretics increase the excretion of electrolytes and fluid, which leads to the activation of the renin-angiotensin-aldosterone system. That is why the combination of thiazides with ACE inhibitors and angiotensin receptor blockers is justified clinically and pathophysiologically. On the Russian market there is a large number of such combined preparations: Lorista H (losartan + hydrochlorothiazide), Wals H (valsartan + hydrochlorothiazide), Koaprovel (irbesartan + hydrochlorothiazide), Lysinoton H (lisinopril + hydrochlorothiazide), Capozide (captopril + hydrochlorothiazide) and many others.

In recent years, much attention has been paid to the combination of an "ACE inhibitor + calcium channel blocker". In two large clinical trials - ASCOT and ACCOMPLISH - this combination was shown to be superior to the combination "beta blocker + thiazide diuretic" and "ACE inhibitor + thiazide diuretic", respectively. Thus, in patients with newly diagnosed high-grade arterial hypertension (2 and 3), treatment should begin with these combinations. Preparations on the Russian market: Equator (amlodipine + lisinopril), Prestans (amlodipine + perindopril), Coriprene (lercanidipine + enalapril) and others.

The key principles of combined antihypertensive therapy are presented in the scheme:

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