medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/ms2022-056medsovet-7539Research ArticleКАРДИОЛОГИЯCARDIOLOGYОсобенности и проблемы лечения артериальной гипертонии у пожилых пациентовFeatures of the treatment of arterial hypertension in elderly patientshttps://orcid.org/0000-0001-8228-1114ЛеоноваМ. В.LeonovaM. V.

Леонова Марина Васильевна - доктор медицинских наук, профессор, член-корр. РАЕН, клинический фармаколог, член Московского регионального отделения.

400005, Волгоград, ул. Коммунистическая, д. 50

Marina V. Leonova - Dr. Sci. (Med.), Professor, Corr. Member RAEN, Clinical Pharmacologist, Member of the Moscow Regional Branch.

50, Kommunisticheskaya St., Volgograd, 400005

anti23@mail.ruМежрегиональная общественная организация «Ассоциация клинических фармакологов»РоссияInterregional Public Organization “Association of Clinical Pharmacologists”Russian Federation2023180820230131623Copyright © Леонова М.В., 20232023Леонова М.В.Leonova M.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/7539

Артериальная гипертония (АГ) представляет проблему в пожилом возрасте как важный сердечно-сосудистый фактор риска. У пожилых пациентов часто выявляется форма изолированной систолической АГ (ИСАГ) с высоким уровнем систолического  (САД) и  низким уровнем диастолического артериального давления  (ДАД), что влияет на  безопасность лечения. Необходимость антигипертензивной терапии у таких пациентов получила убедительные доказательства в эффективности снижения смертности и сердечно-сосудистых осложнений.

Цель научного обзора – повысить осведомленность о проблеме лечения АГ у пожилых пациентов, в частности, при низком ДАД. Представлены результаты исследований и метаанализов по оценке эффективности и безопасности стандартного и интенсивного снижения САД и влияния антигипертензивной терапии на ДАД, особенно при исходно низком ДАД (<70 мм рт. ст.). В исследованиях определены основные группы антигипертензивных препаратов, обеспечивающих эффективное и безопасное снижение АД у пожилых пациентов, обладающих кардиопротективным действием и не влияющих негативно на сопутствующие заболевания. К ним относятся: тиазидоподобные диуретики, блокаторы кальциевых каналов, при дополнительных показаниях и сопутствующих состояниях – блокаторы ренин-ангиотензин-альдостероновой системы. В  метаанализах показаны преимущества интенсивного снижения САД < 120 мм рт. ст. перед стандартным целевым уровнем САД < 140 мм рт. ст. у пожилых пациентов в виде снижения риска сердечно-сосудистых событий и смертности. Так, интенсивное снижение САД благоприятно для предотвращения 1 случая MАCE (NNT = 38) и 1 случая смертности (NNT = 85); а показатель вреда в виде артериальной гипотонии был значительно высоким (NNН = 778). По влиянию на уровень ДАД у пожилых пациентов выявлена обратная зависимость с неблагоприятными коронарными событиями (J-образная кривая), подтвержденная в ряде исследований (INVEST, ARIC, SPRINT). При исходно низком ДАД отмечено существенное увеличение частоты и относительного риска исходов. Принять решение по антигипертензивной терапии в таких ситуациях непросто. Доказательная база исследований свидетельствует о пользе снижения САД для предупреждения сердечно-сосудистых событий у пожилых пациентов, но с осторожностью и индивидуальным подходом.

Arterial hypertension (AH) is one of the most common problems in the elderly and one of the most important cardiovascular risk factors. AH in the elderly has features with a high incidence of ISAH and is characterized by a high level of SBP and a low level of DBP, which creates certain problems for the safety of treatment. The need for antihypertensive therapy in elderly patients has received convincing evidence of the effectiveness of reducing mortality and cardiovascular complications. The purpose of this scientific review was to raise awareness of the problem of treating hypertension in elderly patients, including those with low DBP. The results of studies and meta-analyzes evaluating the efficacy and safety of standard and intensive SBP reduction in elderly patients, as well as the results of the effect of antihypertensive therapy on DBP levels, especially at baseline low DBP (<70 mmHg), are presented. The studies identified the main groups of antihypertensive drugs that provide an effective and safe reduction in blood pressure in elderly patients, have a cardioprotective effect and do not adversely affect comorbidities. These include: diuretics of the thiazide-like group, calcium channel blockers, as well as additional indications and concomitant conditions – ACE inhibitors and antigotensin II receptor blockers. Several meta-analyses have shown the  benefit of  intensively lowering SBP < 120 mmHg before the standard target level SBP < 140 mmHg. in elderly patients as a lower risk of fatal and non-fatal cardiovascular events and overall mortality. Thus, the impact of intensive SBP reduction was beneficial in preventing 1 case of MACE (NNT = 38) and in preventing 1 case of total mortality (NNT = 85); while the rate of harm in the form of arterial hypotension was significantly high (NNH = 778). With regard to the effect on the level of DBP in elderly patients with hypertension or ISAH, an inverse relationship between DBP and adverse coronary events was revealed and a J-curve was described, confirmed in a number of studies (INVEST, ARIC, SPRINT). Moreover, with an initially low DBP (<70 mmHg), a significant increase in the frequency of outcomes and the relative risk of outcomes was noted. It is not easy to decide on antihypertensive therapy in such situations. The evidence base of studies suggests the benefit of lowering SBP for the prevention of cardiovascular events in elderly patients, but with caution and individual approach. It is important to take into account individual patient characteristics such as cognition, autonomy, and frailty/frailty when setting target BP.

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The authors declare that there are no conflicts of interest present.