RU2463043C1 - Method of increasing efficiency of short-term and middle-term antihypertensive therapy and reduction of left ventrucle hypertrophy in patients with arterial hypertension of 2-nd phase of 2-nd degree of risk 3 - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardiology and deals with increase of antihypertensive therapy efficiency and reduction of left ventricle hypertrophy in patients with arterial hypertension of 2-nd degree with high risk of development of cardio-vascular complications (risk 3). For this purpose antihypertensive therapy is performed taking into account prevailing temperament or prevailing part of vegetative nervous system, as well as personality anxiety. With account of said factors elaborated are versions of complex therapy, namely: a) beta-adrenoreceptor antagonist (BAA) and diuretic in average day dose in combination with anxiolytic in minimal day dose; b) BAA and diuteric in minimal day dose; c) ACE inhibitor and diuretic in average day dose in combination with antidepressant in minimal day dose; d) ACE inhibitor and diuretic in minimal day dose and antidepressant in minimal day dose.

EFFECT: method ensures efficient treatment of arterial hyopertension and prevention of acute disorders in blood circulation system due to differentiated administration of drug therapy taking into account psychoemotional background in said group of patients.

5 ex, 23 tbl

Description

The invention relates to medicine, more specifically to cardiology.

The main role in maintaining homeostasis of blood pressure and cardiac function belongs to the sympathetic nervous system, as well as other pressor systems, such as the renin-angiotensin system and vascular endothelium (Wenzel RR, H. Bruck, A. Mitchell, RFSchaefers, D. Baumgart, R Erbel, U. Heeman, Th. Philipp. Interaction of the sympathetic nervous system with other pressor systems in antihypertensive therapy / J Clin Cardiol 2001; 4: 185-192).

It is known that the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system are in close physiological relationship, providing fine regulation of the activity of the heart and blood vessels. This connection is bidirectional, each system activates the other during stimulation. These mechanisms play a crucial role in the formation of arterial hypertension (AH), maintaining a high level of blood pressure and the development of target organ damage (V.I. Podzolkov, K.K. Osadchiy. New horizons for the combination therapy of arterial hypertension / Physician, 2008, No. 6).

One of the target organs in hypertension is the myocardium. It is known that antihypertensive drugs reduce left ventricular hypertrophy, but to a different extent.

In the domestic and foreign literature on hypertension, the content of the hormones cortisol, aldosterone and insulin is often examined: in patients with essential hypertension, an increase in the content of these hormones in the blood serum is noted. Cortisol and aldosterone contribute to the delay in the body of sodium chloride, which leads to the accumulation of fluid in the body, increase the volume of circulating blood and increase blood pressure. Aldosterone in combination with insulin promotes cell proliferation, including vascular smooth muscle cells (arterioles) (Makolkin V.I. Microcirculation and target organ damage in hypertension / Cardiology, 2006; 2: 83-85; Sidorenko G.I. Is the concept reasonable Supplement the “target organ” with the category “dynamic target” / Cardiology, 2009, 2: 73-76; Semke GI, Mordvin VF Structural and functional manifestations of cerebrovascular pathology in patients with essential hypertension / Therapeutic Archive, 2007, 1 : 38-43). In patients with hypertension, this is combined with a decrease in the diameter of blood vessels and an increase in total peripheral vascular resistance, which leads to the progression of the disease and complications (Mukhin N.A., Fomin B.V. Renin - the target of direct pharmacological blockade in arterial hypertension / Therapeutic archive, 2009, 8: 5-9).

Antihypertensive agents of neurotropic action, inhibiting the sympathetic nervous system, are, in particular, beta-blockers (BAB), which reduce systemic blood pressure and myocardial oxygen demand. Anti-hypertensive agents that affect RAAS are RAAS inhibitors - angiotensin-converting enzyme (ACE inhibitors) inhibitors (Medical Textbook / Pharmacology / Antihypertensive Agents (Part 2).

ACE inhibitors are not limited to RAAS. They act on both main systems that regulate blood pressure (sympathetic-adrenal system and RAAS), exerting a systemic effect, including on four main target organs - myocardium, brain, kidneys, arterioles (Bova A.A., Trisvetova E.L. ACE inhibitors and arterial hypertension / Medical Panorama, 2003, No. 8).

According to the order of the Ministry of Health and Social Development of the Russian Federation dated November 22, 2004 No. 254 "On the approval of the standard of care for patients with arterial hypertension", 6 groups of drugs are assigned to the main drugs for the treatment of patients with arterial hypertension: diuretics, BAB, ACE inhibitors, calcium antagonists, alpha 1-blockers, central alpha agonists -2-adrenergic receptors and selective agonists of imidazoline receptors. This regulatory source provides a large list of tests and examinations that should be carried out in relation to a patient with arterial hypertension, but there are no recommendations for choosing certain drugs from these groups for a particular patient.

In the treatment of hypertension, the drugs listed in the above order of the Ministry of Health and Social Development can be used as monotherapy or in combination with each other. It was found that in about half of patients with hypertension, the disease can be effectively controlled by prescribing one antihypertensive drug in combination with following recommendations for correcting adverse lifestyle factors. This means that the remaining 50% of patients may need to use 2 or more antihypertensive drugs to adequately control their blood pressure (An effective combination of two or more antihypertensive drugs: European Society for the Study of Hypertension (ESH) recommendations / Peter A. van Zwieten , Csaba Farsang / European Society of Hypertension Scientific Newsletter. 2003; 4: No. 18; Clinical Cardiology Reviews - No. 1 September 2005).

In the work of Podzolkov V.I. and Osadchy K.K. “New horizons in the combination therapy of arterial hypertension” (Physician, 2008, No. 6) states: “... the need to use combined therapy in the treatment of hypertension is justified by the multifactorial nature of the disease and the heterogeneity of mechanisms for increasing blood pressure. The combination of various factors and mechanisms in each patient individually and theoretically could be taken into account when choosing a therapy. However, at the moment there are no reliable and accessible methods for identifying the principal mechanisms for increasing blood pressure in a particular patient with hypertension. This leads to the fact that in practice the doctor often has to deal with a lengthy selection of antihypertensive therapy using the “trial and error” method, without guaranteeing the result. ”

In a thesis by OA Pleiko “Comparison of different tactics for selecting antihypertensive therapy on an outpatient basis” (2008), it is stated that there are three main approaches to the tactics for selecting antihypertensive therapy. The first approach involves a consistent change in the class of drugs used in order to find the most effective in a particular patient. The main drawback of this approach can be a large number of visits and corresponding changes in therapy, which leads to a deterioration in patient adherence to treatment. Another approach is the stepwise prescription of treatment, in which, in case of insufficient effectiveness of one of the drugs, after increasing its dose, another drug is added, then the third one until the target blood pressure values are reached. A study by O.A. Pleiko showed that this approach is accompanied by a deterioration in patient adherence to therapy and the highest economic costs for treatment. The third approach is to use a combination of different classes of drugs, which allows you to simultaneously act on two alternative links of the pathogenesis of hypertension. A study by O.A. Pleiko showed that with this approach, in comparison with the other two, the target level of blood pressure is faster.

There are no recommendations in the dissertation on the choice of drug classes for combination therapy of the patient.

Known patent of the Russian Federation 2144783 "Method for the selection of drugs for the treatment of arterial hypertension", which consists in the fact that the patient conducts an analysis of heart rate variability, determines the power of the spectrum of ultra-low-frequency oscillations (VLF) and when VLF is less than 30 points, beta-blockers are prescribed, and when a value of more than 150 points - calcium antagonists, angiotensin-converting enzyme inhibitors, or a combination thereof.

Patients with hypertension with a power spectrum of ultra-low-frequency oscillations (VLF) of less than 30 points according to the Russian Federation 2144783 are characterized by energy deficiency, a decrease in metabolic processes. Most often these are patients with low activity of the sympathetic part of the autonomic nervous system. Somewhat doubtful is the fact that the appointment of a BAB during energy deficiency, which reduces the activity of the sympathetic part of the autonomic nervous system and thereby further reduces energy supply in the body, made it possible to relieve energy deficiency and normalize blood pressure. Perhaps the authors took into account some other parameters of the patient when choosing therapy, but this is not mentioned in the text of the description of the invention.

For patients with a high level of spectrum power (VLF over 150 points) according to the invention according to the Russian Federation 2144783 it is better to prescribe calcium antagonists. An increase in blood pressure in these patients occurs against the background of hyperactivity of the hypothalamic-pituitary-adrenal system (HHF), the sympathetic department of the autonomic nervous system, thyroid gland, RAAS, which leads to an increase in the synthesis of glucocorticosteroids, catecholamines, thyroid hormones, renin, angiotensin II and aldosterone. As the author indicates, some patients in this group had to combine a calcium antagonist with an ACE inhibitor to achieve a persistent antihypertensive effect. Probably, the group of patients with a VLF spectrum power of more than 150 points included patients with different activity of GNSS and RAAS, as well as sympathicotonia and parasympathicotonia. But they were not allocated to separate groups, and therefore, the method does not allow to specify whether to treat the patient using only a calcium antagonist or calcium antagonist in combination with an ACE inhibitor. This increases the time before the start of effective treatment of the patient, which is fraught with complications (heart attack, stroke).

In the patent of the Russian Federation 2144783 the sample size of the examined patients is not indicated, their gender, age. The examples that are given in the description relate to the relief of decompensation in patients with hypertension-2 on the background of hypertensive crisis. The method does not take into account the psychological state of the patient — the presence or absence of anxiety or depression, the gender of the patient is not taken into account.

Wide boundaries in the purpose of the method (men, women; all adult age groups; second-stage arterial hypertension of various degrees and risk, in a state of compensation and decompensation; different psychological state of patients) usually reduce the effectiveness of its use.

Known RF patent 2275165 for the invention of "Method for the individual selection of antihypertensive drugs." Before taking medications, the patient is given a 24-hour ECG recording. Blood pressure is measured every 6 hours. A temporary analysis of heart rate variability is carried out according to the results of daily ECG monitoring. An antihypertensive drug in an average therapeutic dose is prescribed to the patient. Within 24 hours, an ECG is recorded with a simultaneous measurement of blood pressure every 6 hours, and the data is processed. Evaluate the results with recommendations on the appropriateness of using this medication in this patient, taking into account a comparison of the variability indices SDNN, rMSSD, SDANN (i) before and after taking the antihypertensive drug. The method allows you to recommend objective criteria that allow you to make an individual choice of antihypertensive drugs.

In this patent there is no indication of the age, sex group of patients for the treatment of which this method is intended, the sample size of the examined patients. The patient’s psycho-emotional stress is not taken into account, its severity and its relief is not expected. Meanwhile, there are works that indicate the need for a psychometric examination of patients with hypertension in order to identify subclinical depression and anxiety (V.R. Weber, M.P. Rubanova, I.A. Sukhenko, P.M. Gubskaya "The effect of amlodipine and metoprolol on autonomic indicators in case of cold and psychoemotional stress in patients with arterial hypertension with different psychoemotional backgrounds ”/ Rational Pharmacotherapy in Cardiology, 2006, v.2, No. 3, pp. 26-31). These circumstances can lead to insufficient effectiveness of the method in people of one age or another, sexual group, with one or another psycho-emotional background. The method is based on ECG monitoring, which is not always and not in all medical institutions possible.

Known RF patent No. 2302816 "Method for the selection of drugs for the treatment of arterial hypertension." The method is based on a spectral analysis of cardiac rhythm variability with recording wave frequencies in the LF ranges from 0.075 to 0.15 Hz, HF from 0.16 to 0.5 Hz, as well as in the range of very low-frequency VLF waves from 0.025 to 0.074 Hz and ultra-low-frequency UVLF waves from 0 to 0.024 Hz. The values of the functions of the power spectral density in these ranges are determined and the total power density of the Power cardiorhythm is found by the formula Power = Power _HF + Power _LF + Power _VLF + Power _UVLF , where Power _HF is a function of the spectral power density of high-frequency waves, points; Power _LF - a function of the spectral power density of low-frequency waves, points; Power _VLF - a function of the spectral power density of very low-frequency waves, points; Power _UVLF - a function of the spectral power density of ultra-low-frequency waves, points; and with a Power value of less than 50 points, beta-blockers are prescribed, with a Power value in the range of 50-150 points, angiotensin-converting enzyme inhibitors are prescribed, with a value exceeding 150 points, calcium antagonists are prescribed.

In this work, the sample size of the examined patients and their age are not indicated. The method does not take into account the gender of the patient, the presence of high or low anxiety, depression and does not imply their relief. The method does not take into account, against the background of an increase in sympathetic or parasympathetic influences, the patient proceeds with hypertension. It is intended for the treatment of patients with hypertension of various stages and degrees. These circumstances usually reduce the effectiveness of the method in a given age or gender group, with one or another psycho-emotional background, in patients with hypertension of one stage or another. In addition, for the implementation of the method requires a vegetation tester.

As mentioned above, one of the factors influencing the onset of hypertension is personal anxiety. In the work of I.V. Gagulin, V.V. Gafarova, E. A. Gromova, Yu.N. Kabanova, A. V. Gafarova “Personal anxiety as a personality trait and the risk of hypertension” (World of science, culture, education. 2009, No. 5 (17)), the effect of personal anxiety on the risk of hypertension in men aged 25-64 years for 16 years was studied. It was shown that in the studied male population for 5 years, the risk of developing AH was 6.8 times, for 10 years it was 5 times higher in people with high personal anxiety compared with people with an average level of anxiety.

In the work of G.A. Usenko, L.E. Panin, A.G. Usenko, K.V. Rasstrig, E.S. Maltsev, S.A. Tokarev “Correlation between reactive anxiety and some functional indicators of flight operators labor ”(Bulletin SB RAMS, 2002, No. 1 (103)), it was shown that taking into account both anxiety and temperament more objectively reflects the body's resistance to various loads.

Surgical methods for treating left ventricular hypertrophy in hypertension are known, for example, according to RF patent 2253373. In patients with hypertrophic non-obstructive cardiomyopathy, the zone of maximum hypertrophy is excised. Excision is performed according to the level of maximum protrusion of the interventricular septum into the cavity of the left ventricle from the cavity of the right ventricle. Atypical trabeculae between the interventricular septum and the anterior wall of the right ventricle are excised. Transesophageal intraoperative echocardiography is performed. The sizes of the cavities of the right and left ventricles, the thickness of the interventricular septum and the diastolic function of the ventricles of the heart are evaluated. The incision of the wall of the right ventricle in the conical part is closed with a continuous atraumatic suture. The method allows to increase the size of the cavity of the left ventricle.

The surgical method for treating left ventricular hypertrophy carries all the risks of surgical intervention, therefore conservative methods of treatment are preferred if it is possible to avoid surgical intervention.

A known therapeutic method for the treatment of left ventricular hypertrophy in patients with coronary heart disease in combination with hypertension (RF patent 2382644). For 6 months, standard drug therapy is carried out, consisting of ACE inhibitors, beta-blocker, aspirin and statin. Additionally, ivabradine is administered in a daily dose of 5-15 mg in 2 divided doses daily. The method provides the transformation of left ventricular hypertrophy into concentric remodeling of the left ventricle and thus reduces the risk of cardiovascular complications.

According to this method, ivabradine, statin, aspirin, ACE inhibitors and BAB are used, which increases the load on the liver.

Known RF patent 2065744 for the invention of a "Method for the treatment of hypertension of the 2nd stage." The method allows to offer objective quantitative biochemical criteria for the individual selection of antihypertensive monotherapy with calcium antagonists. Before and after a two-week administration of a calcium antagonist, the level of insulinemia (ANN) and the beta-adrenergic reactivity of cell membranes (APM) are determined, the membrane stabilizing effect index (IME) is calculated by the formula: IME = (ANN × APM ₁ ) / (APM ₂ -APM ₂ ) and with its value from 5 to 100 conventional units continue treatment, with a value of more than 100 - they switch to treatment with other antihypertensive drugs.

In four out of 5 examples, patients had left ventricular hypertrophy.

In the examples for patients, it was noted that they had a feeling of internal tension, fear, anxiety, but anxiolytic was not prescribed to patients. The method was developed for a small (17 people) heterogeneous group of patients: the age range ranged from 25 to 63 years, the duration of the disease from 1 year to 30 years, the disease status in the group of patients was determined only by stage (stage 2 hypertension), men and women were in the group . However, it is known that in men, hypertension proceeds somewhat differently than in women: in men, hypertension occurs more often with high activity of GNH, and in women - RAAS. Perhaps for this reason, the description does not provide a single example of the successful treatment of women, although the method is intended for the treatment of not only men. For 2 months of treatment in patients who had before treatment the mass of the left ventricular myocardium in the range of 132-191 g, it decreased by 1-3 g. Of the 17 patients treated by the described method, only 10 managed to lower blood pressure.

The above methods do not allow to differentiate the doses of drugs to patients depending on the severity of the studied parameters associated with AH.

Disclosure of invention

The essence of the proposed method of treatment (or: a method for selecting drugs for treatment) of arterial hypertension of the 2nd degree of the 2nd stage, risk 3 and left ventricular hypertrophy in men aged 40-65 years is as follows.

The patient determines the prevailing temperament or the predominant part of the autonomic nervous system - sympathetic or parasympathetic, as well as the level of personal anxiety and if:

- the patient’s prevailing temperament is choleric or sanguine (or the sympathetic part of the autonomic nervous system prevails), and the anxiety level is high, he is prescribed a diuretic and BAB in the average daily therapeutic dose, as well as anxiolytic in the minimum effective daily therapeutic dose,

- the patient’s prevailing temperament is choleric or sanguine (or the sympathetic part of the autonomic nervous system prevails), and the level of anxiety is low, he is prescribed a diuretic and BAB in the minimum effective daily therapeutic dose,

- the prevailing temperament in the patient is phlegmatic or melancholic (or the parasympathetic part of the autonomic nervous system predominates), and the anxiety level is high, he is prescribed a diuretic and ACE inhibitors in the average daily therapeutic dose, as well as an antidepressant in the minimum effective daily therapeutic dose,

- the prevailing temperament in the patient is phlegmatic or melancholic (or the parasympathetic part of the autonomic nervous system predominates), and the level of anxiety is low, he is prescribed a diuretic and ACE inhibitors in the minimum effective daily therapeutic dose.

In addition to the abbreviations that were introduced in the section "prior art", the following abbreviations are used:

AGT - antihypertensive therapy,

HELL - blood pressure

ANS - autonomic nervous system,

LVH - left ventricular hypertrophy,

DBP - diastolic blood pressure,

E / A - coefficient characterizing the diastolic function of the left ventricle (see below),

IWT - initial vegetative tone,

LVMI - left ventricular myocardial mass index,

MLJ - the mass of the left ventricular myocardium,

IOC - minute volume of blood circulation,

OPSS - total peripheral vascular resistance,

GARDEN - systolic blood pressure,

PV - ejection fraction,

FU - shortening fraction,

Heart rate - heart rate,

M - faces with a melancholy temperament,

C - persons with a sanguine temperament,

F - persons with phlegmatic temperament,

X - persons with choleric temperament,

MW, MNT - persons with a melancholy temperament and high or low level of anxiety, respectively,

Svt, Snt - persons with a sanguine temperament and a high or low level of anxiety, respectively,

Fvt, Fnt - persons with phlegmatic temperament and high or low level of anxiety, respectively,

Хвт, Хнт - persons with choleric temperament and high or low level of anxiety, respectively.

The technical results of the invention are as follows:

1. high efficiency of the method based on the study of a large homogeneous sex (men), age (44 - 62 years), severity of the disease (AH - 2 degree II stage II risk 3) of a group of patients ordered by their temperament (the predominant part of the ANS) and level of anxiety. The values of the studied parameters in patients of the main subgroups, where the treatment was carried out according to the proposed method, after 6 and 12 months significantly differed from their values in patients in the comparison subgroups, where the treatment was carried out without taking into account the temperament or the prevalence of one or another department of the ANS, without taking into account the psychoemotional background in patients and without taking into account the severity of their changes that are associated with hypertension and left ventricular hypertrophy. The dynamics of changes in the values of these indicators in the vast majority of cases was better in the main subgroups than in the comparison subgroups. After 12 months of treatment, the values of the studied indicators in the main subgroups and comparison subgroups changed as follows:

- among highly anxious persons, in the main subgroups, the SBP decreased by 17.3-20.2% (hereinafter, the smallest and greatest significance of the change is indicated), and in the comparison subgroups it decreased only by 11.2-11.8%; among low-anxious individuals, in the main subgroups, SBP decreased by 20.9-21.9%, and in the comparison subgroups - by 15.3-17.4%;

- among highly anxious individuals in the main subgroups, the DBP values decreased by 16.9-20%, and in the comparison subgroups - only by 8.95-12.2%; among low-anxious individuals in the main subgroups, the DBP values decreased by 15.3-23.5%, and in the comparison subgroups - only by 11.5-14%;

- in six of the eight main subgroups, LVM decreased by 37-45 g, and in the corresponding subgroups of comparison only by 23-29 g;

- PV increased in the main subgroups by 6.8-10.3%, and in the comparison subgroups - only by 2.4-4.5%;

- FU increased in the main subgroups by 5.7-7.2%, and in the comparison subgroups only by 1.7-3.2%;

- E / A coefficient in the main subgroups was higher than in the comparison subgroups;

- OPSS decreased in the main subgroups by 228-1153 kPa · s · cm ^-5 , and in the comparison subgroups - only by 31-726 kPa · s · cm ^-5 ;

- in highly anxious individuals in the main subgroups, the share of complications in the form of acute cerebrovascular accident and acute myocardial infarction was significantly lower than in the corresponding comparison subgroups: in X - 4.3 times, in C - 2.6 times, in F - 3.9 times, in M - 2.9 times; among low-anxious individuals: in X - 8 times, in C - 4.7 times, in F - 5.3 times, in M - 5 times. Moreover, the number of the most formidable complications — acute cerebrovascular accidents — during treatment according to the proposed method decreased in highly anxious individuals in the main subgroups compared to the corresponding comparison subgroups: in X - 4 times, in C - 3 times, in Ф - 2 , 5 times, in M - 1.5 times, and among low-anxious persons - in X - 5 times, in C - 2.5 times, in F - 2 times, in M - 2 times;

2. the greatest preventive efficacy of the method in relation to acute cerebrovascular accident manifests itself in X, in relation to acute myocardial infarction - in F;

3. the speed of the method - the testing time to determine the temperament and level of anxiety is 30-40 minutes;

4. ease of implementation of the method (does not require special equipment, the method can be used in any medical institution (clinic, hospital);

5. The method allows you to assign a lower dose of drugs to those individuals who, due to their temperament (degree of increase in the activity of the sympathetic or parasympathetic nervous system) and the level of anxiety associated with the disease, changes in the studied parameters are less pronounced.

The rationale for the method

Based on the literature and their own observations, the authors of the proposed method undertook a study of the effectiveness of therapy with officially recommended drugs in a large group of men with stage 2 hypertension, degree 2 risk 3, depending on the prevailing temperament, the prevailing (sympathetic or parasympathetic) ANS division, level of anxiety, depression.

In the conditions of clinics, 1070 men of physical labor aged 44-62 years (average 54.2 ± 1.8 years) suffering from essential (primary) hypertension (stage 2), stage 2, and 2 were examined (Table 1). degrees with the presence of 3 or more risk factors (risk factors: male, age more than 40 years old, smoking, drinking alcohol, table salt). The presence of hypertension in individuals who have not previously received antihypertensive therapy was determined on the basis of the criteria set out in the recommendations [1999 World Heart Organizations - International Society of Hypertansion Guideline for the Management of Hypertension. J. Hypertension, 1999;

17: 151-183].

The disease duration in the examined patients averaged 11.6 ± 1.4 years. The severity of LVH was different. In 96% of cases, the subjects examined did not have a concomitant pathology that impeded the continuation of labor activity.

The control was 502 healthy men without cardiac pathology, compatible with patients according to a number of key indicators, including by age, profession, place of residence.

The prevailing temperament was determined using the psychological test Eysenck and Belov test by 5-fold testing on different days [Stolyarenko L.D. Eysenck’s questionnaire for determining temperament The basics of psychology. Rostov-on-Don: Phoenix, 1997, 440 p.].

No analogies were found with type “A” and type “B”.

The value of personal anxiety and reactive anxiety was determined according to the Spilberger-Khanin test. The differences between personal and reactive anxiety in the examined individuals in most cases did not exceed 2-3 points, which made it possible to unequivocally identify a high or low level of anxiety. In the same cases when, after triple testing, the test results on the personal and reactive anxiety scales did not coincide, they were guided by the indications on the personal anxiety scale.

Men who scored 30-32 points were assigned to low-anxiety, and from 40 points and higher to high-anxiety [Khanin Yu.L. Anxiety study in sports. Psychology issues. M., 1978; 6: 94-106].

The presence and level of depression was determined by the method of Akhmetzhanov E.R. (Akhmetzhanov ER The scale of depression. Psychological tests. Moscow: Liszt, 1996: 11-13], according to which, if the subject scores 20-50 points, then he does not have depression, 51-59 points - there is a slight depression; 60 -69 points - there is a subdepressive state (masked depression), 70 points and above - true depression.

The value of the level of depression in Hvt was 39.6 ± 0.4 points, and in SVT - 42.6 ± 0.5 points, which, according to Akhmetzhanov E.R., was interpreted as the absence of depression; the value of depressiveness in PW was 58.0 ± 0.6, and in MW - 61 ± 0.6 points, which was interpreted as a mild depressive state.

Psychoneurologists believed that highly anxious patients did not need in-patient correction of anxiety and depression.

The values of depression for CNT amounted to 24.6 ± 0.6 points, for SNT - 27.0 ± 0.6 points, for PST 30.1 ± 0.4 and for MNT - 38.2 ± 0.5 points, t. e. they did not have depression.

The equilibrium between the sympathetic and parasympathetic divisions of the ANS was determined by IWT according to the recommendations of Wayne A.M. et al. [A.M. Wayne, T.G. Voznesenskaya, V.L. Golubev. Diseases of the autonomic nervous system / Ed. A.M. Vein. - M .: Medicine, 1991. - 39-84].

Serum levels of cortisol, aldosterone and insulin were determined by the radioimmune method using commercial reagent kits from CEA-IRE-SORIN (France, Italy). The study was carried out from 8.00 to 10.00 in the morning on an empty stomach.

All subjects underwent echocardiography (EchoCG) on a Siemens Sonoline G 50 apparatus using a P4-2 multi-frequency sector transducer. At the same time, in the B-mode, the left ventricular PV and the IOC of the left ventricle were determined. In the M-mode, the final diastolic size (CRD) of the left ventricle, the diastolic and systolic thickness of the posterior wall of the left ventricle (TSSL), and the thickness of the interventricular septum (TML) were measured.

CML was calculated on the basis of its length and thickness along the short axis from parasternal access according to the formula R. Devereux and N. Reichek: 1.04 x (TMSL + TZSLZH (diastolic) + KDR) ³ -KDR ³ ] - 13.6, and LVMI according to the formula: LVMI = LVML / body area in m ² . For normal LVMI in men, values of less than 134 g / cm ² [R. Devereux, N. Reichek. Echocardiographic determination of left ventricular mass in man. Circulation, 1977; 55: 613-813; Teiccholtz LE, Kreulen T., Herman MV Problems in echocardiographic volume determinations: echocardiograhpic correlation in the presence or absence of asynergy / Am. J. Cardiol., 1976; 37: 7-11; 1999 World Heart Organizations - International Society of Hypertansion Guideline for the Management of Hypertension. J. Hypertension, 1999; 17: 151-183].

In patients with echocardiography, a concentric LVH without signs of asymmetric LVH was detected, since the ratio of UTI / TSSL was less than 1.5 [Verdecchia P., Schillaci G. Asymmetric left ventricular remodeling due to isolated septal thickening in patients with tsystemic hypertension.-Am. J. Cardiol, 1994; 73: 247-252; R. Devereux and N. Reichek Echocardiographic determination of left ventricular mass in man. Circulation, 1977; 55: 613-813].

To assess the contractile function of the left ventricle, the values of PV and FU were used.

To assess the diastolic function of the left ventricle, we used the value of the maximum velocity of the transmissible blood flow to the diastole — peak E (E, cm / s), the blood flow velocity to the atrial systole — peak A (A, cm / s) and the coefficient E / A, conv. units A sign of impaired diastolic function is considered to be a decrease in the E / A coefficient of less than 1.0 [Teiccholtz L.E., Kreulen T., Herman M.V. e.a. Problems in echocardiographic volume determinations: echocardiograhpic correlation in the presence or absence of asynergy / Am. J. Cardiol., 1976; 37: 7-11].

We studied heart rate, SBP and DBP three times after an interval of 3-5 minutes on both hands (the difference did not exceed 5.2 ± 1.5 mm Hg).

OPSS was studied by tetrapolar rheography using a 6-NEG apparatus (Germany) with computer data processing [1999 World Heart Organizations - International Society of Hypertansion Guideline for the Management of Hypertension. J. Hypertension, 1999; 17: 151-183].

After the initial testing of the patient, after 6 and 12 months, the study of vegetative tone, hormone content of cortisol, aldosterone, insulin, KDR, TMZHP, TZSLZH, E, A, FV, FU, IOK, heart rate, OPSS was repeated.

Patients were interviewed for adherence to long-term therapy, agreed to long-term treatment, but antihypertensive therapy was combined with periodic disruption of work, rest, treatment, nutrition (taking salt food, alcohol).

The results were processed by methods of variation statistics using the standard software package "Statistica" and t-student test.

The work was carried out in accordance with the provisions of the Helsinki Declaration on the treatment and examination of patients.

Patients were treated with the drugs specified in Order No. 254 of the Ministry of Health and Social Development of the Russian Federation dated November 22, 2004 “On Approving the Standard of Medical Care for Patients with Hypertension” and in the 1999 World Heart Organizations - International Society of Hypertansion Guideline for the Management of Hypertension. J. Hypertension, 1999; 17: 151-183 ”(see above), but not all drug groups were used. Drugs such as α-blockers, as well as angiotensin-II receptor antagonists, were not economically viable for the family budget of patients. Calcium antagonists were initially used in treatment, but up to 40% of patients receiving this drug noted a decrease in potency. For this reason, the drug was not prescribed in the future and BAB was used in treatment (most often, due to its effectiveness and economic availability for patients, metoprolol was prescribed), ACE inhibitors (most often, enalapril was prescribed for the same reasons) and diuretics (most often, veroshpiron and hydrochlorothiazide) .

In addition, if the patient had complaints indicating depression, confirmed by the test data, the patient was prescribed an antidepressant, in most cases - coaxil, rarely - zoloft. Coaxil has not only the properties of an antidepressant, but also a light anxiolytic. Tricyclic antidepressants, such as amitriptyline and the like, with prolonged treatment contributing to the progression of coronary heart disease, were not prescribed.

If the patient had complaints indicating anxiety, confirmed by the test data, he was prescribed anxiolytic, most often sibazon, less often coaxil. Anxiolytic and antidepressant were not prescribed to drivers.

At the beginning of the study, the prescription of antihypertensive drugs (diuretics, BAB, ACE inhibitors) to patients was based on the information contained in the prior art. After data were obtained on several hundred patients with hypertension (primary group), they were analyzed. Patients with hypertension were divided into groups according to temperament - X, C, F and M. Inside these groups, patients were distributed according to the predominant part of the autonomic nervous system. Table 2 shows the results of determining the predominant division of the ANS (sympathicotonia and parasympathicotonia) in people of different temperaments among patients and healthy, obtained on the entire sample of patients and healthy individuals at the end of the study. In 97-100% C and X, the sympathetic division of the ANS was predominant, in 98% F and M the parasympathetic division. In the primary group of examined patients, the results were close.

Explanations for the table: UT - level of anxiety, BT - high-anxiety faces, NT - low-anxiety faces, 1 - comparison group, 1a - main group, n - number of people; record “55 people (out of 56) - 98.2% ”should be read as follows: in 55 out of 56 people who made up a subgroup of highly anxious individuals of choleric temperament, sympathicotonia was observed, i.e. in 98.2% of cases.

Since the overwhelming majority of C and X was predominantly sympathetic, while the overwhelming majority of F and M had the parasympathetic division of the ANS, in the further analysis we focused on patient groups formed by temperament.

Within groups of individuals with the same temperament, subgroups of highly anxious and low-anxious individuals were identified.

An analysis of depression showed that among highly anxious and low-anxiety X and C persons with depression were very few. According to the data calculated for the entire sample at the end of the study, in Hvt and Svt, the proportion of persons with mild depression both in the comparison group and in the main group was 1.78% (1 person out of 56) and 2.67% (2 person out 75) respectively (about the “main group” and the “comparison group” see below).

Depression was not observed in the subgroups of low anxiety F and M.

Conversely, most highly anxious F and M showed mild depression.

According to the data calculated for the entire sample at the end of the study, the proportion of people with mild depression in the study group in the FW was 96.6% (i.e., 115 out of 119 people) and 94.2% in the MW group (t .e. was at 49 people from 52); the proportion of people with mild depression in the comparison group for FW was 87.4% (there were 97 of 111 people), and for MW - 94% (47 of 50 people).

The treatment results of the examined patients were analyzed. Those patients whose positive treatment results were manifested most rapidly were allocated to the main group, which was divided into subgroups according to temperament and level of anxiety of patients. The remaining patients formed a comparison group, which was also divided into subgroups according to temperament and level of anxiety. The successful treatment of patients in the main group, which formed the basis of the proposed method, was as follows. C and X took a diuretic and BAB, and highly anxious of them - an additional anxiolytic. F and M took a diuretic and an ACE inhibitor, and highly anxious of them, who had depression, also took an antidepressant.

The comparison group included persons whose treatment was different, i.e. C and X took a diuretic and an ACE inhibitor or diuretic, an ACE inhibitor and a BAB, with only a fraction of the highly anxious C and X taking an anxiolytic. F and M took a diuretic and a BAB or diuretic, a BAB and an ACE inhibitor, and only part of the highly anxious ones took an antidepressant.

Subsequently, the treatment of patients was based on the results of the analysis of the primary group, and the distinguished main group and the comparison group were replenished to 50 or more people in each subgroup of these groups (Table 1).

The following treatment was carried out in subgroups of the main group of patients.

X and C took a diuretic and BAB. Highly anxious X and C took a diuretic and BAB in the average daily therapeutic doses, and low anxiety X and C took a diuretic and BAB in the minimum effective daily therapeutic doses.

As a diuretic, X and C were prescribed hypothiazide, indapamide, veroshpiron, etc., but in the vast majority of cases - hypothiazide, which was taken at 25 mg / day with Hvt and Svt, and 12.5 mg / day at Chnt and Snt.

Of the drugs of the BAB X and C group, atenolol was prescribed (XBT and CBT at 0.05 g 2 times a day, CNT and CBT at 0.025 g 2 times a day), labetalol (XB and CBT at 100 mg 2 times a day, XBT and SNT - 100 mg once a day), oxprenolol (XBT and SVT - 20 mg 3 times a day, and CNT and SNT - 20 mg 2 times a day), etc., but in the vast majority of cases, metoprolol was prescribed ( or its analogs), which were taken at 200 mg / day for XBT and SVT, and 100 mg / day for CNT and SNT.

The anxious X and C also took anxiolytics. In 96% of cases - sibazon 2.5 mg or coaxil 12.5 mg in the morning and at night.

F and M took a diuretic and an ACE inhibitor. Highly anxious F and M took a diuretic and an ACE inhibitor in average daily therapeutic doses, and low anxiety F and M took a diuretic and an ACE inhibitor in minimum effective daily therapeutic doses.

As a diuretic, F and M took veroshpiron (in 75% of cases), less often - hypothiazide and others. Fvt and MW took veroshpiron 125-150 mg / day, hypothiazide - 25 mg / day; and Fnt and Mnt took veroshpiron 75-100 mg / day, hypothiazide - 12.5 mg / day.

As an ACE inhibitor, F and M took captopril (PW and MW - 25 mg 2 times a day, PF and MNT 12.5 mg 2 times a day), quinapril (PW and MW - 2.5-5 mg 2 times per day, PF and MNT - 2.5-5 mg 1 time per day), lisinopril (PW and MW - 10 mg 2 times a day, PF and MNT - 5 mg 2 times a day), etc., but most often enalapril or its analogies. PW and MW took enalapril at 20 mg / day, PF and MNT took 10 mg / day.

In addition, FW and MW took an antidepressant. As antidepressant in 96%, coaxil was prescribed at 12.5 mg in the morning and at night, in other cases, zoloft at 25 mg / day or others.

As before, anxiolytic or antidepressant was not prescribed for drivers.

All patients took panangin 1-2 tablets 2 times a day and aspirin 0.25 g in the morning after meals (or cardiomagnyl 1 tablet / day).

Tables 3-13 (they are at the end of the text) present the results obtained on the entire array of examined patients and healthy people. The following notation is introduced in the tables:

number 1 (one or with the letter “a”) is included in the designation of subgroups of anxious persons, figure 2 - in the designation of subgroups of anxious persons for each temperament,

subgroups with the designations "1a" and "2a" belong to the main group where treatment was carried out according to the proposed method. The metric values for these subgroups are shown in bold,

subgroups, indicated only by the numbers 1 and 2 (without a letter), belong to the comparison group,

healthy - a control group of people of the same temperament and level of anxiety.

In healthy individuals, the ratio of sympathetic and parasympathetic influences is associated with temperament and anxiety level (Table 3). In healthy X and SVT, the sympathetic division of the ANS predominates; in F, M, and SNT, the parasympathetic division of the ANS predominates. A high level of anxiety enhances the predominance of one or another ANS division in healthy X, F, and M. The predominant influence of the parasympathetic ANS division in SNT is replaced by the predominant influence of the sympathetic ANS division in St.

Compared with healthy patients, X, F, M, and SVT, the degree of predominance of one or another department of the ANS is exacerbated. In patients with SNT, an equilibrium of the ANS divisions is observed.

The results of treatment in the main subgroups significantly differ from those in the comparison subgroups after 6 and 12 months. In seven of the eight main subgroups (except SNT), vegetative tone after 12 months. AHT is more close to the vegetative tone of healthy individuals of the same temperament and anxiety level than in the comparison subgroups. Deviation of vegetative tone in highly anxious patients after 12 months. treatment of its values in healthy individuals of the same temperament and level of anxiety amounted to only 1.6-2.7% in the indicated seven main subgroups (the smallest and largest deviations are indicated), and in the comparison subgroups from 7.8% to 14.4% in individuals with different temperaments. Deviation of vegetative tone values in low-anxious patients after 12 months. treatment for its values in healthy individuals of the same temperament and anxiety level in the seven main subgroups was only 1.4-3.8%, and in the comparison subgroups from 3 to 20% in people with different temperaments.

Thus, the treatment according to the proposed method had a more effective leveling effect on the vegetative tone than treatment in the comparison group.

In healthy individuals, the cortisol content, as shown in Table 3, is also associated with temperament and anxiety level. The highest content of cortisol is observed in blood serum X, the lowest - in M, and in all highly anxious individuals, the content of cortisol is higher than in low-anxious individuals of the same temperament.

In patients X and C, before treatment, the content of cortisol is higher, and in patients F and M it is lower than its content in healthy individuals of the same temperament and level of anxiety.

The treatment results in the main subgroups and comparison subgroups reliably differ from each other after 6 and 12 months of treatment. In patients in the main subgroups, the cortisol content was closer to its content in healthy individuals of the same temperament and level of anxiety than in the comparison subgroups. Deviation of the cortisol content in patients after 12 months of treatment from its content in healthy individuals of the same temperament and anxiety level amounted to 7.6 to 22% in the comparison subgroups, and only 0.4-2.5% in the main subgroups.

The content of aldosterone in healthy people is also not the same in individuals with different temperament and level of anxiety (Table 4). The smallest it is for X, the largest for M, and for all highly anxious persons it is higher than for low-anxious persons of the same temperament.

In all patients, the content of aldosterone before treatment is higher than in healthy individuals of the same temperament and level of anxiety.

Treatment by the proposed method more effectively reduced the content of aldosterone than treatment in the comparison subgroups: the content of aldosterone in the blood serum and after 6, and after 12 months of treatment by the proposed method was significantly lower than in the comparison subgroups. Deviation of aldosterone content in patients after 12 months of treatment from healthy individuals of the same temperament and anxiety level in the comparison subgroups was from 12.9 to 25.8%, and in the main subgroups - from 2.6 to 9%.

The insulin content in healthy individuals, as shown in Table 4, also correlates with temperament and anxiety level. The smallest it is in X, the largest is in M, and for all highly anxious persons it is less than for low-anxious persons.

The insulin content in patients X and C before treatment was lower, and in F and M it was higher than in healthy individuals of the same temperament and level of anxiety.

The treatment results in the main subgroups and comparison subgroups reliably differ from each other after 6 and 12 months of treatment. The treatment according to the proposed method is more effective than the treatment in the comparison subgroups brought the insulin content in patients closer to its content in healthy individuals of the same temperament and anxiety level. Deviation of the insulin content in patients after 12 months of treatment from its content in healthy individuals of the same temperament and anxiety level amounted to 2.7 to 10.5% in the comparison subgroups, and only 0.6-3% in the main subgroups.

Table 5 presents data on the GARDEN.

Among healthy individuals, the highest SBP values are in X, the smallest - in M. In highly anxious individuals, SBP values are higher than in low-anxious individuals of the same temperament.

In patients before treatment, the values of SBP are significantly and significantly higher than in healthy individuals of the same temperament and level of anxiety.

Treatment by the proposed method more effectively reduced the SBP than the treatment of patients in the comparison group. Values of SBP in the main subgroups at each treatment period are significantly lower than in the comparison subgroups. After 12 months of treatment, in high-anxious individuals, in the comparison subgroups, the SBP decreased only by 11.2-11.8%, and in the main subgroups - by 17.3-20.2%; among low-anxious individuals in the comparison subgroups - by 15.3-17.4%, and in the main subgroups - by 20.9-21.9%. At the same time, in the highly anxious F and M after 12 months of treatment according to the proposed method, the SBP values became lower than 140 mm Hg. (in the comparison subgroups - remained higher).

Table 6 presents the data for DBP. In healthy, highly anxious individuals, the lowest DBP is observed in X, and the highest in M. In healthy, low-anxious individuals, the DBP does not differ in individuals of different temperaments.

In all patients before treatment, the DBP values are higher than in healthy individuals of the same temperament and level of anxiety, and in low-anxiety patients, the lowest DBP is also observed in X before treatment, and the highest in M.

The DBP values in the main subgroups at each treatment period are significantly lower than in the comparison subgroups. Treatment by the proposed method more effectively approximated the DBP values to those in healthy individuals of the same temperament and level of anxiety. After 12 months of treatment, in anxious individuals in the comparison subgroups, the DBP values decreased by 8.95-12.2%, and in the main subgroups - by 16.9-20%; among low-anxious individuals in the comparison subgroups, the DBP values decreased by 11.5-14%, and in the main subgroups - by 15.3-23.5%.

As Table 7 shows, LVMI and LVMI in healthy individuals are also associated with temperament and level of anxiety: the lowest values of these indicators are in X, the highest in M, and in all highly anxious individuals, these indicators have higher values than in low-anxiety ones.

In all patients, before treatment, CML and LVMI are significantly higher than in healthy individuals of the same temperament and level of anxiety.

The treatment according to the proposed method is more effective than in the comparison group, reduced LVMI and LVMI in six out of eight subgroups (except for SVT and MW): the values of these indicators in these subgroups are significantly lower than in the comparison subgroups. After 12 months of treatment, LVM in six main subgroups decreased by 37-45 g, and in six comparison subgroups it decreased only by 23-29 g.

Table 8 shows the data on PV and PV.

FV and FU in healthy people of different temperament and level of anxiety are not the same: these values have the highest values for X, the lowest for M, and for all highly anxious individuals, their values are lower than for low-anxiety ones.

In all patients before treatment, the values of EF and FU are lower than in healthy individuals of the same temperament and level of anxiety.

The treatment according to the proposed method is more effective than in the comparison group, increased the PV and FU values: after 6 and 12 months of treatment, the PV and FU values in the main subgroups were significantly higher than their values in the comparison subgroups. After 12 months of treatment, PV increased in the comparison subgroups only by 2.4-4.5%, and in the main subgroups - by 6.8-10.3%. FU after 12 months of treatment in the comparison subgroups increased only by 1.7-3.2%, and in the main subgroups - by 5.7-7.2%.

Table 9 shows the data characterizing the diastolic function of the left ventricle. The E / A coefficient has different meanings in healthy people: this indicator has the greatest value for X, the least for M, and for highly anxious individuals of all temperaments, E / A values are lower than for low-anxiety ones.

In all patients before treatment, the E / A coefficient has lower values than in healthy individuals of the same temperament and level of anxiety, and in highly anxious individuals it is about half as much.

The treatment by the proposed method is more effective than in the comparison group, increased the E / A coefficient: after 6 and 12 months of treatment, its values in patients of the main subgroups are significantly higher than in the comparison subgroups.

Table 10 presents heart rate data. Among healthy individuals, the highest heart rate is observed in X, the lowest - in M. In all highly anxious individuals, heart rates are higher than in low-anxious individuals of the same temperament.

In patients with HBT and SVT before treatment, heart rate values are higher than in healthy individuals of the same temperament and level of anxiety. In patients with Fnt and Mnt, heart rate values are lower than in healthy individuals of the same temperament and level of anxiety. In the remaining subgroups of patients, the values of heart rate before treatment does not differ from those in healthy individuals of the same temperament and level of anxiety.

In X and C, treatment according to the proposed method successfully reduced heart rate values than treatment in the comparison group: heart rates after 6 and 12 months of treatment in the main subgroups were significantly lower than heart rates in the comparison subgroups.

Table 11 shows the IOC data. In healthy individuals, the IOC indicator has the highest value in X, the least - in M, and in highly anxious X, F, and M, IOC has higher values than in low-anxiety. In high-anxiety and low-anxiety C, the IOC values do not differ.

In patients X and SVT before treatment, the IOC values are higher than in healthy individuals of the same temperament and level of anxiety. In SNT before treatment, the IOC value does not differ from its value in healthy SNT. In patients with F and M, before treatment, IOC has lower values than in healthy F and M of the same level of anxiety.

Treatment by the proposed method more effectively reduced the IOC values of C and X: IOC values after 6 and 12 months of treatment in the main subgroups were significantly lower than in the comparison subgroups.

Table 12 summarizes the OPSS. Values of OPSS in healthy individuals are related to temperament and anxiety level and significantly differ in individuals of different temperaments. The highest values of OPSS are in M, the lowest are in X, and in all highly anxious individuals, the values of OPSS are higher than in low-anxiety persons.

In sick people before treatment, the values of OPSS are higher than in healthy individuals of the same temperament and level of anxiety.

The treatment according to the proposed method is more effective than in the comparison subgroups to reduce OPSS: after 6 and 12 months of treatment, the values of OPSS in the main subgroups are significantly lower than in the comparison subgroups. After 12 months of treatment, OPSS decreased in the comparison subgroups only by 31-726 kPa · s · cm ^-5 , and in the main subgroups - by 228-1153 kPa · s · cm ^-5 .

As indicated above, the treatment of men both in the comparison subgroups and in the main subgroups was accompanied by a periodic violation of the regime of work, rest, treatment, nutrition (intake of salty food, alcohol), which was reflected in the treatment results.

Table 13 presents the absolute and relative number of people who had complications in the form of acute cerebrovascular accident (stroke) or acute myocardial infarction (AMI) after 6 and 12 months of treatment.

As can be seen from the data presented, the proportion of persons with complications in all the main subgroups is significantly lower than in the corresponding comparison subgroups in all periods of the study — after 6 and 12 months of treatment. The share of complications in the main subgroups of highly anxious individuals was as follows: in X - 8% (in the comparison subgroup - 34%), in C - 20.7% (in the comparison subgroup - 55.8%), in F - 19.6% ( in the comparison subgroup - 79.6%), in M - 28% (in the comparison subgroup - 80%), and for low-anxious persons - the following: in X - 2% (in the comparison subgroup - 16%), in C - 5, 77% (in the comparison subgroup - 27.5%), in F - 5.55% (in the comparison subgroup - 30.8%), in M - 6% (in the comparison subgroup - 30%).

Analysis of the ratio of ONMK / AMI in patients with different temperaments showed that in X and Svt the number of strokes exceeds the number of heart attacks, and in F, M and Snt the inverse ratio is observed.

The ratio of ONMK / AMI in the main subgroups of highly anxious individuals was as follows: for X - 3/1 (in the comparison subgroup - 12/5), in C - 6/5 (in the comparison subgroup - 17/12), in Ф - 4/7 (in the comparison subgroup - 10/33), in M - 6/8 (in the comparison subgroup - 9/31), and for low-anxious persons - as follows: in X - 1/1 (in the comparison subgroup - 5/3), in C - 2/2 (in the comparison subgroup - 5/9), in Ф - 2/2 (in the comparison subgroup - 4/12), M - 2/2 (in the comparison subgroup - 4/11).

Below are examples of treatment of patients by the proposed method and in the comparison group. Examples are presented by pairs of patients of the same temperament, anxiety level with the presence or absence of depression, close in age, height, profession, clinic of the disease. The first of a pair of patients was treated in accordance with the proposed method, and the second patient was from the comparison group.

In the First report of experts of the Scientific Society for the Study of Arterial Hypertension of the All-Russian Scientific Society of Cardiology and the Interdepartmental Council for Cardiovascular Diseases "Prevention, Diagnosis and Treatment of Primary Arterial Hypertension in the Russian Federation" (DAG 1) (Russian Medical Journal, 2000, vol. 8, No. 8, p. 318-349) criteria for the effectiveness of antihypertensive therapy are given. According to DAG 1, the criterion for the effectiveness of short-term therapy (short-term therapy is considered to be 1-6 months long) is a decrease in systolic and / or diastolic blood pressure by 10% or more or the achievement of the target level of blood pressure. The target blood pressure level is a pressure below 140/90 mmHg. The criterion for the effectiveness of medium-term therapy (therapy lasting more than 6 months) is to achieve the target values of blood pressure.

In DAG 1, the criterion for the effectiveness of AHT is only for blood pressure. You can use the principle of DAG 1 with respect to other indicators: a change in their values by 10% (from the initial to the target) after 6 months of therapy and the achievement of the target values of these indicators after 12 months of treatment can be considered additional evidence of the effectiveness of AHT. As the target values of the indicators, we take their values in healthy individuals of the same temperament and level of anxiety).

In tables 14-23 below, the initial (before treatment) values of the studied parameters of the patients are shown, as well as the values of these indicators after 6 and 12 months of treatment. In the columns "Difference from the original" indicates the change in the initial value of the indicator after 6 and 12 months of treatment, calculated by the formula: (Ref.-PL) / Ref × 100%, where Ref. - the initial value of the indicator, PL - the value of the indicator after treatment). The column “Healthy” shows the values of indicators in healthy individuals of the same temperament and level of anxiety. The abbreviation in the tables: D - depression, LT - personal anxiety.

Example 1

Example 1 shows information about two patients with choleric temperament with a predominant influence of the sympathetic division of the ANS, a high level of anxiety without depression, one of which was treated by the proposed method (example 1.1), and the other, as described in example 1.2.

1.1. The treatment according to the proposed method

Patient K. Novov, 51 years old (turner) complained of frequent headache, irritability, increased fatigue until the end of the working day, decreased working capacity, poor sleep (short, restless). Father died at work; mother suffered from hypertension and died of a stroke; brother is treated for stage 2 hypertension.

The values of heart rate and blood pressure, measured repeatedly at home and in the clinic, as well as at the workshop doctor, were within the boundaries of grade 2 hypertension (see below). Fundus: Keith-Wagener-Barker grade 2 hypertensive retinopathy (retinal angiopathy) (Salus II). According to the ECG and DEHOKG there are signs of LVH (see below). Associative diseases were not detected. Diagnosis: hypertension of the 2nd degree of the 2nd stage, risk 3. The patient refused hospital treatment for a number of reasons.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin 0.25 g once a day in the morning after eating; metoprolol 100 mg × 2 times a day (morning and evening); hypothiazide 25 mg once a day in the morning; panangin 2 tablets 2 times a day after meals; sibazon 2.5 mg in the morning and at night. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The growth of the patient is 173 cm; body weight - 80 kg; BMI - 26.7 (overweight), body area (S) = 1.93 m ² .

After 6 months of treatment, the values of SBP and DBP decreased by more than 10% (SBP - by 16.3%, DBP - by 13%), while the value of DBP reached the target level (decreased below 90 mm Hg). After 12 months of treatment, the value of SBP also reached the target level. Changes in the values of SBP and DBP according to DAT 1 indicate that therapy by the proposed method was effective.

The values of most other indicators (seven out of ten) after 6 months of AHT changed towards the target value (decreased or increased) by more than 10%, and after 12 months of treatment, the values of six of ten indicators (IWT, D, LT, HR, IOC, E / A) began to correspond to their values in healthy people. MMWF, which had a value of 302.7 g before treatment, after 12 months of treatment decreased by 51 g and amounted to 251.1 g.

These changes serve as additional evidence of the effectiveness of AGT.

1.2. Example from comparison group

Patient Pen-n V., 54 years old (turner), complained of a diffuse headache, worse by the end of the worker in the back of the head and temples, as well as nosebleeds 1-2 times a month. He drew the attention of the doctor to his high irritability, temper, impatience, conflict. Efficiency decreased, sleep became superficial.

From the anamnesis it is known that father was treated for hypertension, suffered a stroke; the mother died due to acute myocardial infarction (was treated for hypertension); sister - 38 years old, healthy.

GARDEN from 160 to 169 mm Hg The optometrist noted the presence of hypertensive retinopathy - degree 2 retinal angiopathy according to Keith-Wagener-Barker (Salus II). According to the ECG and DechoCG, the patient has signs of LVH (see below). Associative diseases were not detected. Diagnosis: hypertension of the 2nd degree, stage II, risk 3.

The patient refused hospital treatment. He was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles. Salt is recommended to use no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin 0.25 g once a day in the morning after eating; enalapril (ACE inhibitor) 10 mg 2 times a day (morning and evening); hypothiazide 25 mg in the morning 1 time per day; panangin 2 tablets 2 times a day after meals. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The growth of the patient is 176 cm; body weight - 84 kg; body mass index (BMI) - 27.1 (overweight), S body = 2.0 m ² .

After 6 months of treatment, the values of SBP and DBP decreased by less than 10% (SBP - by 7.3%, DBP - by 8.2%), but the DBP value reached the target level (decreased to 90 mm Hg). After 12 months of treatment, the value of the SBP did not reach the target level. The dynamics of the values of SBP and DBP indicates that AHT in the comparison group was not sufficiently effective.

The values of only one of the 10 other indicators (HR) after 6 months of AHT changed (decreased) by more than 10%. After 12 months of treatment, the values of these 10 indicators were still far from their values in healthy people. MMVD, which had a value of 300.8 g before treatment, after 12 months of treatment decreased by only 11.9 g and amounted to 288.9 g.

The information provided provides additional evidence of the lack of effectiveness of the AGT.

Example 2

This example provides information about two patients with phlegmatic temperament with a predominant influence of the parasympathetic division of the ANS, a high level of anxiety and mild depression. One of them was treated according to the proposed method (example 2.1), and the other as indicated in example 2.2.

2.1. The treatment according to the proposed method

Patient A. Nest-sov, 53 years old, (turner), complained to the general practitioner in the clinic about a moderate headache in the temples and back of the head, a decrease in working capacity, and interest in events that previously worried him. Apathy was combined with a sleep disorder: for a long time I could not fall asleep, sleep lasted 3-4 hours, was superficial. Changes in life status are noted throughout the year. There were no episodes of nosebleeds, but in some cases noted flickering of black dots, "flies" in front of the eyes.

Mother is being treated for hypertension; father suffers from coronary heart disease; the sister is under the supervision of a therapist for vegetovascular dystonia.

Optometrist's conclusion: hypertensive retinopathy (angiopathy) of the retinal vessels, according to Keith-Wagener-Barker degree 2 (Salus II). According to ECG and DEHOKG there are signs of left ventricular LVH (see below). Associative diseases were not detected. Diagnosis: hypertension of the 2nd degree of the II stage, risk 3. The patient refused hospital treatment for several reasons.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin 0.25 g once a day in the morning after eating; enalapril 10 mg 2 times a day (morning and evening); Veroshpiron 125 mg in the morning 1 time per day; coaxil 12.5 mg morning and night (5 days off after 14 days of treatment); panangin 2 tablets 2 times a day after meals. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The height of the patient is 177 cm, body weight 85.0 kg, BMI = 27.1 kg / m ² (excess body weight); S body surface = 2.02 m ² .

After 6 months of treatment, the values of SBP and DBP in the patient decreased by more than 10% (SBP - by 10.6%, DBP - by 11.8%), while the value of DBP reached the target level (90 mmHg). After 12 months of treatment, the value of SBP also reached the target level. Changes in the values of SBP and DBP according to DAG 1 indicate that AGT by the proposed method was effective.

The values of most other indicators (6 out of 10) after 6 months of AHT changed toward the target value (decreased or increased) by more than 10%, and after 12 months of treatment, the values of IWT and RT began to correspond to their values in healthy people. LML, which had a value of 436.6 g before treatment, after 12 months of treatment decreased by 110.4 g and amounted to 326.2 g.

These changes serve as additional evidence of the effectiveness of AGT.

2.2. Example from comparison group

Patient Sem-n, N., 52 years old (turner), complained to the general practitioner at the clinic about a decrease in working capacity, interest in life, weakness, and depression for no reason. Changes in status are noted during the year when headaches appeared in the temples, the forehead. There were no episodes of nosebleeds, but in some cases noted the flickering of "flies" in front of the eyes. Mother was treated for hypertension, and irregularly, she died due to a stroke; father suffers from duodenal ulcer; the brother is under the supervision of a therapist for hypertension of the 2nd degree.

Fundus: hypertensive retinopathy (angiopathy) of the retinal vessels, degree 2 according to Keith-Wagener-Barker (type Salus II). According to the ECG and DechoCG, there are signs of LVH (see below). Associative diseases were not detected. Diagnosis: hypertension 2 degree II stage II, risk 3. The patient refused hospital treatment.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment was prescribed: aspirin 0.25 g once a day in the morning after meals, betalok (metoprolol) 100 mg 2 times a day (morning and evening); hypothiazide 25 mg in the morning 1 time per day; panangin 2 tablets 2 times a day after meals; sibazon 2.5 mg in the morning and at night (a break in admission for 5 days after 14 days of treatment). Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The growth of the patient 177 cm, body weight 85.0 kg, BMI = 27.1 kg / m ² ; S body surface - 2.02 m ²

After 6 months of treatment, the values of SBP and DBP decreased by less than 10% (SBP - by 4.6%, DBP - by 3%), and after 12 months neither SBP nor DBP reached the target values, which indicates that AGT was not effective.

Change in none of the 10 other indicators after 6 months of AHT did not reach 10%. MMWF, which had a value of 434.3 g before treatment, after 12 months of treatment decreased only by 48.7 g and amounted to 385.6 g.

These changes serve as additional evidence of the lack of effectiveness of the performed AGT.

Example 3

Example 3 provides information on the treatment of two patients with melancholic temperament with the predominant influence of the parasympathetic division of the ANS, high levels of anxiety and mild depression. One of them was treated according to the proposed method (example 3.1), and the other, as indicated in example 3.2.

3.1. The treatment according to the proposed method

Patient Nose-in V., 57 years old, turner, has been observed about AH for about 4 years. Not regularly treated. Breaks in treatment - from 3 to 5 months. Notes periodic headaches in the temples and parietal region. Recently, he notes increased fatigue, some apathy, decreased mood, interest in those events in life that previously worried him. If the pain intensifies by the end of the working day, then black “flies” appear before the eyes, occasionally - nosebleeds. Associative diseases not found. Family history: father was treated for hypertension, died of a heart attack; mother is treated for hypertension of the 2nd degree; brother is healthy.

Fundus: degree 2 hypertensive retinopathy according to Keith-Wagener-Barker (Salus II). ECG and DEHOKG data indicate left ventricular hypertrophy.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin 0.25 g in the morning 1 time per day after meals; enalapril 10 mg 2 times a day (morning and evening); Veroshpiron 125 mg in the morning 1 time per day; panangin 2 tablets 2 times a day after meals; coaxil 12.5 mg in the morning and at night. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The patient’s height is 180 cm, body weight is 81.9 kg, BMI = 25.3 (normal). S body surface area - 2.02 m ² .

After 6 months of treatment, the values of SBP and DBP decreased by 10% or more (SBP - by 18.8%, DBP - by 10%), while the value of DBP reached the target level (90 mmHg). After 12 months of treatment, SBP also reached the target level. Changes in the values of SBP and DBP according to DAT 1 indicate that AGT by the proposed method was effective.

The values of 8 out of 10 other indicators after 6 months of AHT changed towards the target value (decreased or increased) by more than 10%, and after 12 months of treatment, the values of 7 out of 10 indicators (IVT, D, LT , IOC, PV, FU, FU, E / A) reached the target level or significantly approached it. MMWF, which had a value of 475.4 g before treatment, after 12 months of treatment decreased by 122.5 g and amounted to 352.9 g.

These changes serve as additional evidence of the effectiveness of AGT.

3.2. Example from comparison group

Patient K-ev V., 56 years old, locksmith, has been observed for hypertension for about 3 years. Not treated. Recently, he notes some apathy, a decrease in mood, interest in those events in life that previously worried him. Complains of periodic headaches, worse by the end of the working day, occasionally - nosebleeds. Family history: mother and father were treated for hypertension, died of a heart attack and stroke; brother is healthy.

Fundus: hypertensive retinopathy, according to Keith-Wagener-Barker degree 2 (Salus II). According to ECG and DEHOKG - left ventricular hypertrophy.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin - 0.25 g once a day in the morning after eating; metoprolol - 100 mg 2 times a day (morning and evening); hypothiazide - 25 mg in the morning 1 time per day, which was changed to veroshpiron 125 mg / day in a month; Panangin - 2 tablets 2 times a day after meals. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The patient’s height is 179 cm, body weight is 81 kg, BMI = 25.3 (normal). S body surface - 2.0 m ² .

After 6 months of treatment, the values of SBP and DBP decreased by less than 10% (SBP - by 3.6%, DBP - by 5%), and after 12 months only the DBP value reached the target level, which indicates that AHT was not quite effective.

Of the 10 other indicators, only the value of IWT after 6 months of treatment increased by 10%, and after 12 months the values of these indicators have not yet approached the target level. MMWF, which had a value of 468.0 g before treatment, after 12 months of treatment decreased by only 63.1 g and amounted to 404.9 g.

The dynamics of the indicators in this patient provides additional evidence of the lack of effectiveness of the performed AHT.

Example 4

Example 4 provides information about two patients with sanguine temperament with an equilibrium state of the sympathetic and parasympathetic divisions of the ANS and a low level of anxiety. One of them was treated according to the proposed method (example 4.1), and the other - as indicated in example 4.2.

4.1. The treatment according to the proposed method

Patient R.-K., 56 years old, electrician, has been observed about AH for about 4 years. Not regularly treated. Breaks in treatment from 2 to 5 months. During the dispensary physical examination complained of periodic headaches in the temples and parietal region. Recently noted increased fatigue, but the tone of life is not reduced. Associative diseases not found. Family history: father is being treated for hypertension, mother died due to acute myocardial infarction; sister (44 years old) is being treated for hypertension of the 2nd degree.

Fundus: hypertensive retinopathy (angiopathy), according to Keith-Wagener-Barker 2 degrees (Salus II). According to ECG and DEHOKG - left ventricular hypertrophy.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin - 0.25 g once a day in the morning after eating; metoprolol (betalok) 100 mg once a day; indapamide - 1.25 mg in the morning 1 time per day; Panangin 1 tablet 2 times a day after meals. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The patient’s height is 176 cm, body weight is 88.0 m, BMI = 28.4 (body weight is excess), S of the body surface is 2.04 m ² .

After 6 months of treatment, the value of SBP decreased by more than 10% (by 11.9%), the value of DBP in this patient was initially 80 mm Hg. After 12 months treatment of SBP and DBP in the patient had a value of 129 and 75 mm Hg respectively, that according to DAG 1 testify to the effectiveness of AGT.

The values of 5 out of 10 other indicators after 6 months of AHT changed towards the target value (decreased or increased) by more than 10%, and after 12 months of treatment, the values of RT, heart rate and IOC significantly approached the target level. MMWF, which had a value of 367.2 g before treatment, after 12 months of treatment decreased by 68.3 g and amounted to 298.9 g.

These changes serve as additional evidence of the effectiveness of AGT.

4.2. Example from comparison group

Patient Tsap-v K., 54 years old, an electric welder, has been observed about AH for about 4 years. Not regularly treated. Breaks in treatment - from 3 to 5 months. Notes periodic headaches of a diffuse nature, as well as in the temples and parietal region. Recently complains of increased fatigue. Associative diseases not found. Family history: father was treated for hypertension, died due to acute myocardial infarction; mother is treated for hypertension of the 2nd degree; my sister showed fluctuations in blood pressure up to 145/90 mm Hg.

Fundus: hypertensive retinopathy according to Keith-Wagener-Barker - 2 degrees (Salus II). According to ECG and DEHOKG - left ventricular hypertrophy.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin - 0.25 g once a day in the morning after eating; enalapril - 10 mg once a day; indapamide - 1.25 mg once daily in the morning; Panangin 1 tablet 2 times a day after meals. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The growth of the patient is 177 cm, body weight - 88.6 kg, BMI = 28.3 (body weight - excess), S = 2.06 m ² .

After 6 months of treatment, the value of SBP decreased by less than 10% (by 3.1%), DBP before treatment was 82 mm Hg. After 12 months of treatment, SBP almost reached the target value, but did not compare with it, which indicates that AHT in the comparison group was not sufficiently effective.

Changes in 10 other indicators after 6 months did not reach 10%, after 12 months the values of RTI, D, LT, IOC approached the target level. MMVD, which had a value of 369.2 g before treatment, after 12 months of treatment decreased by 52.6 g and amounted to 316.6 g.

The results of treatment of this patient were better than that of other patients from the comparison group, however, treatment of the same patient in the main group was more effective.

Example 5

Example 5 provides information on the treatment of two patients with melancholic temperament with a predominance of the parasympathetic division of the ANS and a low level of anxiety. One of them was treated according to the proposed method (example 5.1), and the other, as indicated in example 5.2.

5.1. The treatment according to the proposed method

Patient D.V.N., 57 years old, turner, was observed by a general practitioner for hypertension for about 5 years. Adherence to treatment was low for economic reasons. He noted periodic headaches in the back of the head, but more often in the temples and the parietal region. Notes fatigue, without signs of apathy. Headaches happen in the morning (heavy head). Pain in the head and dizziness occur or intensify with psycho-emotional or physical stress, as well as towards the end of the working day. Rarely (1 time per month) there are black dots ("flies") in front of the eyes, without episodes of nosebleeds. Associative diseases not found. Family history: father, mother, and sister are treated for hypertension.

Fundus: hypertensive retinopathy (angiopathy) according to Keith-Wagener-Barker 2 degrees (Salus II). According to ECG and DechoCG - left ventricular hypertrophy.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin - 0.25 g once a day in the morning after eating; enalapril - 10 mg once a day; hypothiazide - 12.5 mg once a day, in the morning; Panangin - 1 tablet 2 times a day after meals. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The growth of the patient is 180 cm, body weight - 80.8 kg, BMI = 24.9 - the norm. S = 2.01m ² .

After 6 months of treatment, the values of SBP and DBP decreased by more than 10% (SBP - by 10.4%, DBP - by 12.1%), and the value of DBP reached the target level. After 12 months of treatment, SBP and DBP were 128 and 76 mm Hg. respectively, which according to DAG 1 indicates the effectiveness of the performed AGT.

The values of three (D, CML, LVMI) of 10 other indicators after 6 months of AHT decreased by more than 10%, and after 12 months of treatment, the values of RTI, D, LT, HR, IOC, FU and E / A significantly approached target level. MMVD, which had a value of 396.3 g before treatment, after 12 months of treatment decreased by 74.9 g and amounted to 321.4 g.

These changes serve as additional evidence of the effectiveness of AGT.

5.2. Example from comparison group

Patient Nose-n. V., 54 years old, turner, has been observed about AH for about 5 years. Not regularly treated. Notes periodic headaches in the back of the head, but more often in the temples and parietal region. Recently noted increased fatigue, without signs of apathy, although there is a slight decrease in mood. Pain occurs in the morning (heavy head) for no reason, worse at the end of the day. Sometimes there are "flies" in front of the eyes, occasionally - nosebleeds. Associative diseases not found. Family history: father is being treated for hypertension; the mother is being treated for duodenal ulcer; brother is also being treated for peptic ulcer.

Fundus: hypertensive retinopathy (angiopathy) according to Keith-Wagener-Barker 2 degrees (Salus II). According to ECG and DechoCG - left ventricular hypertrophy.

The patient was given recommendations on the correct mode of work, rest; It is recommended to exclude smoking and alcohol, as well as spicy dishes and pickles, to use table salt no more than 2-3 g / day. Outpatient treatment is prescribed: aspirin - 0.25 g once a day in the morning after eating; metoprolol (betalok) - 100 mg 1 time per day in the morning; hypothiazide - 12.5 mg once a day, in the morning; Panangin 1 tablet 2 times a day after meals. Recommended observation by a general practitioner and measuring blood pressure daily 3-4 times a day.

The patient’s height is 179.5 cm, body weight is 82.0 kg, BMI = 25.5 is the norm. S = 2.02 m ² .

After 6 months of treatment, the values of SBP and DBP decreased by less than 10% (SBP - by 2.5%, DBP - by 7.2%), but DBP reached the target value (90 mmHg). After 12 months of treatment, SBP almost reached the target value, but did not compare with it, which indicates that AHT in the comparison group was not sufficiently effective.

Changes in 10 other indicators after 6 months did not reach 10%. After 12 months, the values of RT, heart rate and IOC approached the target level. MMVF, which had a value of 398.5 g before treatment, after 12 months of treatment decreased by only 35.3 g and amounted to 363.2 g.

Treatment of this patient showed a significant improvement in a number of indicators, however, was less successful than in the main group in a similar patient.

Claims (1)

A method for the treatment of arterial hypertension of the 2nd degree of the 2nd stage, risk 3 and left ventricular hypertrophy in men aged 40-65 years, characterized in that the patient determines the prevailing temperament or the predominant part of the autonomic nervous system (sympathetic or parasympathetic), and level of personal anxiety and if:
- the patient’s prevailing temperament is choleric or sanguine (or the sympathetic part of the autonomic nervous system prevails), and the anxiety level is high, he is prescribed a diuretic and BAB in the average daily therapeutic dose, as well as anxiolytic in the minimum effective daily therapeutic dose,
- the patient’s prevailing temperament is choleric or sanguine (or the sympathetic part of the autonomic nervous system prevails), and the level of anxiety is low, he is prescribed a diuretic and BAB in the minimum effective daily therapeutic dose,
- the prevailing temperament in the patient is phlegmatic or melancholic (or the parasympathetic part of the autonomic nervous system predominates), and the anxiety level is high, he is prescribed a diuretic and ACE inhibitors in the average daily therapeutic dose, as well as an antidepressant in the minimum effective daily therapeutic dose,
- the prevailing temperament in the patient is phlegmatic or melancholic (or the parasympathetic part of the autonomic nervous system predominates), and the level of anxiety is low, he is prescribed a diuretic and ACE inhibitors in the minimum effective daily therapeutic dose.