Клинические рекомендации по диагностике и лечению пациентов с артериальной гипертонией и хронической обструктивной болезнью легких

Клинические рекомендации по диагностике и лечению пациентов с артериальной гипертонией и хронической обструктивной болезнью легких

Чазова И.Е., Невзорова В.А., Амбатьелло Л.Г. и др. Клинические рекомендации по диагностике и лечению пациентов с артериальной гипертонией и хронической обструктивной болезнью легких. Системные гипертензии. 2020; 17 (3): 7–34. DOI: 10.26442/2075082X.2020.3.200294

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Chazova I.E., Nevzorova V.A., Ambat'ello L.G. et al. Clinical practice guidelines on the diagnosis and treatment of patients with arterial hypertension and chronic obstructive pulmonary disease. Systemic Hypertension. 2020; 17 (3): 7–34. DOI: 10.26442/2075082X.2020.3.200294

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Аннотация

Одним из наиболее частых коморбидных состояний у лиц старше 40 лет является сочетание артериальной гипертонии (АГ) с хронической обструктивной болезнью легких (ХОБЛ). Частота АГ у больных ХОБЛ варьирует от 6,8 до 76,3%, составляя в среднем 34,3%. ХОБЛ выявляется у каждого 4-го больного АГ в возрасте от 25 до 64 лет. Учитывая устойчивую тенденцию к увеличению продолжительности жизни, число пациентов с коморбидной патологией будет увеличиваться. В целом диагностические мероприятия и тактика лечения АГ и ХОБЛ определяются действующими клиническими рекомендациями для обеих нозологий, однако имеется ряд особенностей при сочетании этих заболеваний в связи с развитием взаимного патологического влияния друг на друга, что приводит к усугублению течения каждого из них. При выборе антигипертензивных препаратов у пациентов с АГ и ХОБЛ предпочтение следует отдавать тем препаратам, которые способны адекватно снижать повышенное артериальное давление (АД) в условиях гипоксии, особенно в ночные и ранние утренние часы, при этом не ухудшая бронхиальную проходимость и гипоксию, иметь пролонгированное действие. Возможным вариантом их применения может быть назначение в вечернее время. Терапия АГ у пациентов с ХОБЛ должна включать рекомендации по изменению образа жизни, в первую очередь прекращение курения. В качестве начальной терапии рекомендуются применение блокаторов кальциевых каналов, блокаторов рецепторов ангиотензина II или ингибиторов ангиотензинпревращающего фермента. В качестве комбинированной терапии 1-й линии рекомендовано применение блокаторов кальциевых каналов/блокаторов ренин-ангиотензин-альдостероновой системы. При недостаточном антигипертензивном эффекте и в зависимости от клинической ситуации возможно назначение тиазидных или тиазидоподобных диуретиков и b1-селективных адреноблокаторов. Основу терапии ХОБЛ в сочетании c АГ составляют бронходилататоры. Согласно современным представлениям комбинирование препаратов с разными механизмами действия является наиболее доказанным и обоснованным подходом относительно снижения частоты обострений ХОБЛ и уменьшения симптомов заболевания. При выборе бронходилататора в случае сочетания ХОБЛ и АГ следует учитывать их доказанную безопасность относительно риска возникновения сердечно-сосудистых осложнений в долгосрочных исследованиях. В режиме монотерапии таким эффектом обладает тиотропия бромид, в том числе в жидкостном ингаляторе, при использовании комбинации – аклидиниум/формотерол и тиотропия бромид/олодатерол. Эскалация терапии ХОБЛ с необходимостью использования ингаляционных стероидов требует тщательного мониторинга уровня АД и, возможно, пересмотра антигипертензивного лечения в сторону его усиления. Применение препаратов при медикаментозной терапии, зависящей от фенотипа заболевания, – рофлумиласта, теофиллина, макролидов и мукоактивных препаратов – также вызывает необходимость более жесткого контроля АД у пациентов с АГ и ХОБЛ.

Ключевые слова: коморбидная патология, артериальная гипертония и хроническая обструктивная болезнь легких, лечение сочетания артериальной гипертонии и хронической обструктивной болезни легких, рекомендации.

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One of the most common comorbid condition in people over 40 years old is: arterial hypertension (AH) and chronic obstructive pulmonary disease (COPD). The frequency of AH in patients with COPD varies from 6.8 to 76.3%, in average 34.3%. COPD is detected in every fourth patient with hypertension in the age group of 25–64 years. The current trend towards an increase in life expectancy and therefore growing pool of elder cohort, will lead to a higher number of patients with comorbid disorders. Diagnosis and treatment of AH and COPD are determined by current clinical recommendations for both nosologies, however, a number of mutual pathophysiological mechanisms lead to a more severe course of these diseases with frequent exacerbations. The choice of antihypertensive therapy in patients with AH in combination with COPD should be given to drugs that can provide an adequate decrease in blood pressure in hypoxic conditions, especially at night and early morning hours, that have prolonged effect or could be prescribed in the evening, and to those that don’t worsen bronchial obstruction or exacerbate hypoxia. Patients with AH and COPD should be given recommendations on lifestyle changes, especially smoking cessation. As initial therapy calcium channel blockers, angiotensin receptor blockers or angiotensin-converting enzyme inhibitors should be considered. Calcium channel blockers/renin-angiotensin system blockers should be considered as the first line for combination therapy. Thiazide, thiazide-like diuretics or b1-selective adrenergic blockers could be prescribed in case of insufficient antihypertensive response or depending on different clinical scenarios. Bronchodilators are the baseline therapy in COPD with concomitant AH. According to modern concepts, prescription of combination therapy with different mechanisms of action is the most proven and justified approach, which leads to a decrease in the frequency of exacerbations of COPD and amelioration of the symptoms. The choice of bronchodilator in the case of a COPD and AH combination, should take into account the proven long-term safety regarding the risk of cardiovascular complications. Tiotropium bromide as the monotherapy, including as a liquid inhaler and aclidinium/formoterol, tiotropium/oladeterol as combination therapy showed cardiovascular safety in the long-term studies. The escalation of COPD therapy with the need of inhaled steroids requires careful monitoring of blood pressure and, possibly, a revision of antihypertensive treatment leading to its escalation as well. COPD has many phenotypes requiring different medications, eg.: roflumilast, theophylline, macrolides and mucoactive drugs, that could also require tighter blood pressure control on patients with COPD and AH.

Key words: comorbid pathology, arterial hypertension, chronic obstructive pulmonary disease, treatment of arterial hypertension and chronic obstructive pulmonary disease combination, recommendations.

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Авторы

И.Е. Чазова*1, В.А. Невзорова2, Л.Г. Амбатьелло1, Т.А. Бродская2, Е.В. Ощепкова1, А.С. Белевский3, Ю.В. Жернакова1, З.Р. Айсанов3, С.И. Овчаренко4, А.Г. Чучалин3

1 ФГБУ «Научный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия;
2 ФГБОУ ВО «Тихоокеанский государственный медицинский университет» Минздрава России, Владивосток, Россия;
3 ФГБОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия;
4 ФГАОУ ВО «Первый Московский государственный медицинский университет имени И.М.Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*c34h@yandex.ru

________________________________________________

Irina E. Chazova*1, Vera A. Nevzorova2, Lali G. Ambatiello1, Tat'iana A. Brodskaia2, Elena V. Oshchepkova1, Andrei S. Belevskii3, Juliya V. Zhernakova1, Zaurbek R. Aisanov3, Svetlana I. Ovcharenko4, Aleksandr G. Chuchalin3

1 National Medical Research Center for Cardiology, Moscow, Russia;
2 Pacific State Medical University, Vladivostok, Russia;
3 Pirogov Russian National Research Medical University, Moscow, Russia;
4 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*c34h@yandex.ru

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