Rationale for the choice of antihypertensive drugs in patients with arterial hypertension and comorbid pathology

Abstract

The comorbidities have mutual impact on each other, character and severity of complications. Comorbidities influence both the choice of antihypertensive drugs and target blood pressure (BP) level. The article reviews the main approaches to the hypertension management in patients with chronic kidney disease (CKD), hyperuricemia and gout, as well as in sleep apnea. CKD affects 8 % to 16 % of the population worldwide. The interaction between arterial hypertension (AH) and CKD is complex and increases the risk of adverse cardiovascular and cerebrovascular outcomes. The most important measures include strict BP control, reduction of proteinuria, and avoidance of further renal harm. Currently, the treatment target for patients with CKD is a systolic BP 130 mm Hg. Nonpharmacological approaches include life style modification, most important of which is salt restriction. Treatment with a combination of antihypertensive drugs is a key component of drug treatment AH in CKD patients. According to recent guidelines, angiotensin-converting enzyme inhibitors (ACEI) should be the drugs of first choice. Angiotensin II receptor blockers (ARB) should be used if the ACEI is not tolerated. Calcium channel blockers (CCB) should not be used as monotherapy in CKD patients but always in combination with a renin-angiotensinaldosteron system (RAAS) blocker. Diuretics are represent the cornerstone in the management of CKD patients. Appropriate diuretic choice, based on estimated glomerular filtration rate.Epidemiological surveys have confirmed the strong relationship of gout and hyperuricaemia with hypertension. AH is found in 36–41 % gout patients, and combined with metabolic syndrome it may reach 80 %. Non-drug measures include following a diet restricted to foods that contain purines. Gout treatment includes drugs that help reduce uric acid levels, because achieving remission of the disease and lowering uric acid levels may in itself be accompanied by a decrease and stabilization of BP. The drugs of choice in patients with a combination of gout and hypertension are metabolically neutral CCB and ACEI, which do not exacerbate hyperuricemia, as well as a representative of the ARB losartan.Obstructive sleep apnea syndrome (OSA) and АH are concomitant diseases, who are both associated with an increased cardiovascular risk. OSA is very common (prevalence is 2–4 % in men and 1–2 % in women of average age) but is frequently undiagnosed. The high prevalence of OSA in the general population, hypertensive patients and especially obese individuals and patients resistant to antihypertensive therapy, highlights the need for effective screening, diagnosis and treatment of syndrome to decrease cardiovascular risk. OSA is characterized by recurrent episodes of partial (hypopnea) or complete interruption (apnea) in breathing during sleep due to airway collapse in the pharyngeal region. The diagnostic standard for OSA is nocturnal polysomnography in a sleep laboratory. Continuous positive airway pressure is the first-line treatment. Other treatment modalities include weight reduction and surgery to correct anatomic obstructions. Taking into account the pathogenesis, the use of antihypertensive drugs that have a sympatholytic effect, including RAAS blockers, is justified. The use of betablocker (BB) and diuretics should be limited to the use of small doses and the use of metabolically neutral members of these classes (highly selective BB, thiazide-like diuretics and aldosterone antagonists, which have been shown to be highly effective in patients with AH and OSA.Therefore, hypertensive patients with coexistent pathologies require individual approach, complex diagnostics and treatment dependent on the type of comorbidity.