Hypertensive reaction hell to the load. Physiological changes during exercise

A - normotonic; B - hypotonic; B - hypertonic; G - dystonic; D - stepped

Normotonic type of reaction of cardio-vascular system characterized by an increase in heart rate, an increase in systolic and a decrease in diastolic pressure. Pulse pressure increases. Such a reaction is considered physiological, because with a normal increase in the pulse, adaptation to the load occurs due to an increase in pulse pressure, which indirectly characterizes an increase in the stroke volume of the heart. The rise in systolic blood pressure reflects the effort of left ventricular systole, and the decrease in diastolic blood pressure reflects a decrease in arteriolar tone, providing better blood access to the periphery. The recovery period with such a reaction of the cardiovascular system is 3-5 minutes. This type of reaction is typical of trained athletes.

Hypotonic (asthenic) type of reaction The cardiovascular system is characterized by a significant increase in heart rate (tachycardia) and, to a lesser extent, an increase in the stroke volume of the heart, a slight rise in systolic and unchanged (or a slight increase) in diastolic pressure. Pulse pressure goes down. This means that an increase in blood circulation during exercise is achieved more due to an increase in heart rate, and not an increase in stroke volume, which is irrational for the heart. The recovery period is getting longer.

Hypertonic type of reaction on physical activity is characterized by a sharp increase in systolic blood pressure - up to 180-190 mm Hg. Art. with a simultaneous rise in diastolic pressure up to 90 mm Hg. Art. and above and a significant increase in heart rate. The recovery period is getting longer. The hypertonic type of reaction is assessed as unsatisfactory.

Dystonic type of reaction cardiovascular system on physical activity is characterized by a significant increase in systolic pressure - above 180 mm Hg. st and diastolic, which after the cessation of the load can drop sharply, sometimes to "0" - the phenomenon of infinite tone. The heart rate rises significantly. Such a reaction to physical activity is regarded as unfavorable. The recovery period is getting longer.

Stepwise type of reaction characterized by a stepwise rise in systolic pressure at the 2nd and 3rd minutes of the recovery period, when the systolic pressure is higher than at the 1st minute. Such a reaction of the cardiovascular system reflects the functional inferiority of the regulatory circulatory system, therefore it is assessed as unfavorable. The recovery period for heart rate and blood pressure is delayed.

Normotonic the type of reaction is characterized by parallelism in the change in heart rate and pulse pressure due to an adequate increase in maximum blood pressure and a decrease in minimum blood pressure. Such a reaction indicates the correct adaptability of the cardiovascular system to stress and is observed in a state of good preparedness. Sometimes in the initial periods of training, there may be a slowdown in the recovery of heart rate and blood pressure.

Asthenic or hypotonic the type is characterized by an excessive increase in heart rate with a slight rise in blood pressure and is assessed as unfavorable. Such a reaction is observed in the state of a break in training due to illness, injury.

Hypertensive type is characterized by an excessive increase in heart rate and blood pressure to the load. An isolated increase in the minimum blood pressure over 90 mm. rt. Art. should also be regarded as a hypertonic reaction. The recovery period is getting longer. Hypertonic reaction occurs in hyperreactors, or in persons with hypertension, or with overwork and overstrain.

dystonic the type of reaction or the phenomenon of "infinite tone" is characterized by the fact that it is practically impossible to determine the minimum blood pressure. If the phenomenon of "infinite tone" is detected only after a 15-second maximum run and the minimum BP is restored within three minutes, then a negative assessment should be treated with great caution.

Reaction with a stepwise rise in maximum blood pressure- when it is higher in the second and third minutes of the recovery period than in the first minute, in most cases it indicates pathological changes in the circulatory system.

BMI = body weight (kg) / height2 (m)

The body mass index (BMI) is used to measure weight for height and provides an acceptable estimate of total body fat in studies involving certain populations. In addition, BMI correlates with both morbidity and mortality, so it provides a direct indicator of health status and morbidity risk.

The method does not provide information about the distribution of fat in different parts of the body, it is difficult to explain to the client and it is difficult to plan the actual loss of body weight due to changes in BMI. In addition, BMI has been shown to overestimate body fat mass in muscular individuals (eg, many athletes) and underestimate in individuals with muscle wasting (eg, the elderly).
Excess weight is defined when BMI is 25 - 29 kg/m2, and obesity - when BMI is greater than 30 kg/m2. In people with a BMI greater than 20 kg/m2, mortality from many health conditions increases with weight.
World Health Organization (WHO), for men and women, recommended BMI, 20 - 25 kg/m2

Vegetative index (Kerdo index)

VI \u003d (1 - ADD / HR) X 100
VI is considered to be one of the simplest indicators of the functional state of the vegetative nervous system, reflecting the ratio of the excitability of its sympathetic and parasympathetic departments (excitation and inhibition, respectively - SSF). The value of VI in the range from -15 to +15 indicates the balance of sympathetic and parasympathetic influences. VI value greater than 15 indicates the predominance of tone sympathetic department of the autonomic nervous system and indicates a satisfactory adaptation to the workload, a VI value of less than minus 15 indicates the predominance of the tone of the parasympathetic division of the autonomic nervous system, which is a sign of the presence of a dynamic mismatch (Rozhentsov, Polevshchikov, 2006; P. - 156).
In a trained person, VI before class is usually with a minus sign, or is in the range from - 15 to + 15.
An excessive increase in VI usually indicates a hypertonic reaction of a person to a load - a discrepancy between the proposed load and the level of fitness. Such loads should not be frequent even for well-trained athletes.
A decrease in VI also indicates poor exercise tolerance. VI values below - 15 indicate the most unfavorable type of reaction of the autonomic nervous system to the load - hypotonic.

Blood pressure (BP)

It is measured at rest, so there should be no activity for 15 minutes before its determination. If the systolic pressure exceeds 126 mm Hg. Art., and diastolic - 86 mm Hg. Art., measure it again after hyperventilation (five maximum deep and rapid breaths of exhalation). if the pressure remains elevated, check the cuff width and read again after 15 minutes. If it continues to be elevated, conduct a deeper examination.
Gender differences do not affect the level of blood pressure, but after puberty (16-18 years), blood pressure in men is slightly higher than in women. Daily fluctuations in blood pressure are at least 10 - 20 mm Hg. Art. and decrease during nighttime sleep.
The horizontal position of the body, physical and mental rest are factors that reduce blood pressure. Eating, smoking, physical and mental stress lead to an increase in blood pressure. With great physical exertion, blood pressure can increase significantly. The reaction of ADD is especially important. In trained athletes, intense exercise is accompanied by a decrease in blood pressure.
BP in obese individuals is higher than in people with normal or underweight (muscle mass). In athletes living in a cold climate, blood pressure is 10 mm Hg. Art. higher, with warm weather, there are tendencies to reduce blood pressure.
Normally, there is asymmetry of pressure: blood pressure on the right shoulder is slightly higher than on the left. In rare cases, the difference reaches 20 or even 40 mm Hg. Art.

Systolic pressure (SBP)

Systolic pressure is considered normal at values from 90 to 120 mm Hg.

A value below 90 is hypotension, most often observed in women due to a small absolute mass of muscles and the body in general, as well as short stature. It may also indicate malnutrition (starvation, non-physiological diet).
Values from 120 to 130 mm Hg - moderately elevated blood pressure. Moderately elevated blood pressure can be observed at rest in individuals with high values of height, body weight and / or muscle mass (especially with a sharp increase in body weight). May be the cause of a person's arousal before exercise, white coat syndrome, or caused by a recent meal.
140 and above are a sign of hypertension, but multiple measurements are required throughout the day to clarify the diagnosis. If the diagnosis is confirmed, the doctor must recommend an appointment medicines normalizing pressure.

Diastolic pressure (DBP)

It is considered normal at values from 60 to 80 mm Hg of the column.

Values from 80 to 90 mm Hg indicate a moderately elevated BPD.
ABP of 90 mm Hg and above is a sign of hypertension.

It should be noted that the final conclusion is made not on the best, but on the worst of the indicators. Thus, both 141 over 80 and 130 over 91 indicate hypertension.

Pulse pressure (PP)

It is defined as the difference between systolic and diastolic pressure. Other things being equal (the same peripheral resistance, blood viscosity, etc.), the pulse pressure changes in parallel with the value of the systolic blood volume (an indirect indicator of myocardial load). Normally, it is 40 - 70 mm Hg. Art. Pulse pressure may increase as a result of an increase in blood pressure or a decrease in blood pressure.

Mean arterial pressure (MAP)

GARDEN \u003d ADD + 1/3 (ADS - ADD)
All changes in the mean blood pressure determined by changes in minute volume (MO) or total peripheral resistance (OPS)
GARDEN \u003d MO x OPS
A normal systolic blood pressure can be maintained against the background of a decrease in TPS due to a compensatory increase in the MO.

Five Types of Cardiovascular System (CVS) Response to Exercise
(Kukolevsky, 1975; Epifanov. 1990; Makarova, 2002)

1. Normotonic type of CCC reaction on physical activity is characterized by:

adequate intensity and duration of the work performed by an increase in heart rate, within 50 - 75% (Epifanov, 1987);
an adequate increase in pulse blood pressure (the difference between systolic and diastolic blood pressure) due to an increase in systolic blood pressure (no more than 15 - 30% (Epifanov, 1987)) and a small (within 10 - 35% (Makarova, 2002), 10 - 25 % (Epifanov, 1987)) by a decrease in diastolic blood pressure, an increase in pulse pressure by no more than 50–70% (Epifanov, 1987).
fast (i.e., within the specified rest intervals) recovery of heart rate and blood pressure to the original values

The normotonic type of reaction is the most favorable and reflects the body's good adaptability to physical activity.

2. Dystonic type of reaction , as a rule, occurs after loads aimed at developing endurance, and is characterized by the fact that diastolic blood pressure is heard to 0 (the "infinite tone" phenomenon), systolic blood pressure rises to values of 180 - 200 mm Hg. Art. (Karpman, 1980). It is possible that a similar type of reaction may occur after a repeated load after class.
With the return of diastolic blood pressure to the initial values for 1-3 minutes of recovery, this type of reaction is regarded as a variant of the norm; while maintaining the phenomenon of "infinite tone" more long time– as an unfavorable sign (Karpman, 1980; Makarova, 2002).

3. Hypertonic type of reaction characterized by:

inadequate load increase in heart rate;
inadequate load increase in systolic blood pressure to 190 - 200 (up to 220) mm Hg. Art. more than 160 - 180% (Epifanov, Apanasenko, 1990) (at the same time, diastolic pressure also slightly increases by more than 10 mm Hg (Epifanov, Apanasenko, 1990) or does not change, which is due to a significant hemodynamic impact during exercise in some athletes (Karpman, 1980));
slow recovery of both indicators.

The hypertonic type of reaction indicates a violation of the regulatory mechanisms that cause a decrease in the efficiency of the functioning of the heart. It is observed in chronic overstrain of the central nervous system (neurocirculatory dystonia of the hypertensive type), chronic overstrain of the cardiovascular system (hypertensive variant) in pre- and hypertensive patients.

4. step response maximum blood pressure is characterized by:

a sharp increase in heart rate;
an increase in systolic blood pressure that continues in the first 2–3 minutes of rest compared with the 1st minute of recovery;

This type of reaction is unfavorable. It reflects the inertia of regulatory systems and is recorded, as a rule, after high-speed loads (Makarova, 2002). Experience indicates that the given type of reaction is associated with a deterioration in the functional state of the athlete's body (Karpman, 1980., P 113). The load execution time (30 s) may be insufficient for the development of the cardiovascular system, which, according to a number of indicators, lasts 1–3 minutes. In some individuals, despite the termination of the load, the deployment of the circulatory function may continue for some time (Karpman, 1980, ibid.). Thus, this type of reaction is most likely to occur after the first 20-squat trial, which is performed before the session.

5. Hypotonic type of reaction characterized by:

a sharp, inadequate load increase in heart rate (up to 170 - 190 bpm (Karpman, 1980); more than 100% (Epifanov, Apanasenko, 1990); up to 120 - 150% (Epifanov, 1987));
the absence of significant changes in blood pressure (systolic pressure slightly or does not increase at all, and sometimes even decreases, pulse pressure decreases (Epifanov, Apanasenko, 1990));
delayed recovery of heart rate and blood pressure.

The hypotonic type of reaction is the most unfavorable. It reflects a violation (decrease) in the contractile function of the heart (“hyposystole syndrome” in the clinic) and is observed in the presence of pathological changes in the myocardium (Makarova, 2002). Apparently, the increase in minute volume is provided mainly by an increase in heart rate, while the increase in systolic volume is small (Karpman, 1980).
Pathological reactions to stress during regular physical training can turn into physiological ones (Epifanov, 1987., P 50). For unfavorable types of reaction, which most often appear at the beginning of the preparatory period (Karpman, 1980., C 114), additional (clarifying) pressure measurements are possible, described (Richard D. H. Backus, and David C. Reid 1998., C 372 ).

Additional Information.

If high-intensity training sessions are planned (especially preparation for competitions), it is necessary that the client undergo a complete medical examination (including a dentist).
To check the state of the cardiovascular system, it is necessary to perform an ECG under stress. Possible pathologies of the myocardium reveals Echocardiogram.
Be sure to evaluate the diet (an analysis of everything that was eaten for a week or more) and the daily regimen - the possibility of organizing an adequate recovery.
It is strictly forbidden to prescribe medicines to a client (especially hormonal ones) - this is the duty of the doctor.

Referral of the client for echocardiography and stress ECG to rule out cardiac pathology is recommended under the following circumstances:

Positive answers to questions about the symptoms of CVD diseases
Slow recovery of heart rate and/or respiration during introductory session
High heart rate and blood pressure with little exercise
Adverse type of reaction to physical activity
History of cardiovascular disease (previous)

Before receiving test results:

The pulse when walking is not higher than 60% of the maximum (220 - age). If possible, introduce additional aerobic exercise on days free from strength training, gradually increasing its duration to 40-60 minutes.
The strength part of the lesson is 30-40 minutes, follow the technique of performing exercises, use a pace of 3: 0.5: 2: 0, while controlling breathing (avoid holding your breath). Use alternating exercises for the "top" and "bottom". Don't rush to increase the intensity
Of the available control methods necessarily use blood pressure measurements before and after training, heart rate before and after (if there is a heart rate monitor, then during the lesson). Observe the rate of recovery of breathing, before it normalizes, do not start the next approach.

The article was prepared by Sergey Strukov

BMI = body weight (kg) / height2 (m)

Vegetative index (Kerdo index)

VI \u003d (1 - ADD / HR) X 100
VI is considered to be one of the simplest indicators of the functional state of the autonomic nervous system, reflecting the ratio of the excitability of its sympathetic and parasympathetic divisions (excitation and inhibition, respectively - SSF). The value of VI in the range from -15 to +15 indicates the balance of sympathetic and parasympathetic influences. A VI value of more than 15 indicates the predominance of the tone of the sympathetic division of the autonomic nervous system and indicates satisfactory adaptation to the workload, a VI value of less than minus 15 indicates the predominance of the tone of the parasympathetic division of the autonomic nervous system, which is a sign of the presence of a dynamic mismatch (Rozhentsov, Polevshchikov, 2006; S. - 156).
In a trained person, VI before class is usually with a minus sign, or is in the range from - 15 to + 15.
An excessive increase in VI usually indicates a hypertonic reaction of a person to a load - a discrepancy between the proposed load and the level of fitness. Such loads should not be frequent even for well-trained athletes.
A decrease in VI also indicates poor exercise tolerance. VI values below - 15 indicate the most unfavorable type of reaction of the autonomic nervous system to the load - hypotonic.

Blood pressure (BP)

Systolic pressure (SBP)

Systolic pressure is considered normal at values from 90 to 120 mm Hg.

A value below 90 is hypotension, most often observed in women due to a small absolute mass of muscles and the body in general, as well as short stature. It may also indicate malnutrition (starvation, non-physiological diet).
Values from 120 to 130 mm Hg - moderately elevated blood pressure. Moderately elevated blood pressure can be observed at rest in individuals with high values of height, body weight and / or muscle mass (especially with a sharp increase in body weight). May be the cause of a person's arousal before exercise, white coat syndrome, or caused by a recent meal.
140 and above are a sign of hypertension, but multiple measurements are required throughout the day to clarify the diagnosis. If the diagnosis is confirmed, the doctor is obliged to recommend taking medications that normalize blood pressure.

Diastolic pressure (DBP)

It is considered normal at values from 60 to 80 mm Hg of the column.

Values from 80 to 90 mm Hg indicate a moderately elevated BPD.
ABP of 90 mm Hg and above is a sign of hypertension.

It should be noted that the final conclusion is made not on the best, but on the worst of the indicators. Thus, both 141 over 80 and 130 over 91 indicate hypertension.

Pulse pressure (PP)

Mean arterial pressure (MAP)

GARDEN \u003d ADD + 1/3 (ADS - ADD)
All changes in mean arterial pressure are determined by changes in minute volume (MO) or total peripheral resistance (TPS)
GARDEN \u003d MO x OPS
A normal systolic blood pressure can be maintained against the background of a decrease in TPS due to a compensatory increase in the MO.

Five Types of Cardiovascular System (CVS) Response to Exercise
(Kukolevsky, 1975; Epifanov. 1990; Makarova, 2002)

1. Normotonic type of CCC reaction on physical activity is characterized by:

adequate intensity and duration of the work performed by an increase in heart rate, within 50 - 75% (Epifanov, 1987);
an adequate increase in pulse blood pressure (the difference between systolic and diastolic blood pressure) due to an increase in systolic blood pressure (no more than 15 - 30% (Epifanov, 1987)) and a small (within 10 - 35% (Makarova, 2002), 10 - 25 % (Epifanov, 1987)) by a decrease in diastolic blood pressure, an increase in pulse pressure by no more than 50–70% (Epifanov, 1987).
fast (i.e., within the specified rest intervals) recovery of heart rate and blood pressure to the original values

The normotonic type of reaction is the most favorable and reflects the body's good adaptability to physical activity.

2. Dystonic type of reaction , as a rule, occurs after loads aimed at developing endurance, and is characterized by the fact that diastolic blood pressure is heard to 0 (the "infinite tone" phenomenon), systolic blood pressure rises to values of 180 - 200 mm Hg. Art. (Karpman, 1980). It is possible that a similar type of reaction may occur after a repeated load after class.
With the return of diastolic blood pressure to the initial values for 1-3 minutes of recovery, this type of reaction is regarded as a variant of the norm; while maintaining the phenomenon of "infinite tone" for a longer time - as an unfavorable sign (Karpman, 1980; Makarova, 2002).

3. Hypertonic type of reaction characterized by:

inadequate load increase in heart rate;
inadequate load increase in systolic blood pressure to 190 - 200 (up to 220) mm Hg. Art. more than 160 - 180% (Epifanov, Apanasenko, 1990) (at the same time, diastolic pressure also slightly increases by more than 10 mm Hg (Epifanov, Apanasenko, 1990) or does not change, which is due to a significant hemodynamic impact during exercise in some athletes (Karpman, 1980));
slow recovery of both indicators.

4. step response maximum blood pressure is characterized by:

a sharp increase in heart rate;
an increase in systolic blood pressure that continues in the first 2–3 minutes of rest compared with the 1st minute of recovery;

5. Hypotonic type of reaction characterized by:

a sharp, inadequate load increase in heart rate (up to 170 - 190 bpm (Karpman, 1980); more than 100% (Epifanov, Apanasenko, 1990); up to 120 - 150% (Epifanov, 1987));
the absence of significant changes in blood pressure (systolic pressure slightly or does not increase at all, and sometimes even decreases, pulse pressure decreases (Epifanov, Apanasenko, 1990));
delayed recovery of heart rate and blood pressure.

Additional Information.

Referral of the client for echocardiography and stress ECG to rule out cardiac pathology is recommended under the following circumstances:

Positive answers to questions about the symptoms of CVD diseases
Slow recovery of heart rate and/or respiration during introductory session
High heart rate and blood pressure with little exercise
Adverse type of reaction to physical activity
History of cardiovascular disease (previous)

Before receiving test results:

The pulse when walking is not higher than 60% of the maximum (220 - age). If possible, introduce additional aerobic exercise on days free from strength training, gradually increasing its duration to 40-60 minutes.
The strength part of the lesson is 30-40 minutes, follow the technique of performing exercises, use a pace of 3: 0.5: 2: 0, while controlling breathing (avoid holding your breath). Use alternating exercises for the "top" and "bottom". Don't rush to increase the intensity
Of the available control methods necessarily use blood pressure measurements before and after training, heart rate before and after (if there is a heart rate monitor, then during the lesson). Observe the rate of recovery of breathing, before it normalizes, do not start the next approach.

The article was prepared by Sergey Strukov

In recent years, there has been an increase in the incidence of arterial hypertension in all age categories. It should be noted that secondary arterial hypertension prevails in children, which, according to various studies, accounts for 65-90% of all cases of pathology, and more often it occurs in children under the age of 10 years.

Thus, the proportion of secondary arterial hypertension (J. Hanna, 1991) in children under 10 years of age reaches 90%; in adolescents - 65% (M.Y. Arar et al., 1994). With increasing age, the frequency of symptomatic (secondary) arterial hypertension decreases to 5-10% (according to some reports, up to 15%) in adults. In young and middle-aged children, kidney diseases, congenital diseases of the heart and blood vessels, endocrine diseases, diseases of the nervous system, and long-term use of certain medications often lead to an increase in blood pressure (BP). Among the causes of increased blood pressure, heavy metal poisoning (lead, mercury), smoking, alcohol abuse, and burns are also distinguished.

According to V.A. Lyusova et al. (2007), more than half of the cases of pathology detected in young men (16-26 years old) referred for examination for arterial hypertension by the military registration and enlistment office were congenital malformations and acquired kidney diseases. The significant prevalence among children and adolescents of secondary arterial hypertension must be remembered in case of accidental detection of elevated blood pressure in them.

An important role in the development of arterial hypertension is played by heredity. So, about half of patients from the general population suffering from this disease indicate the presence of arterial hypertension in two or more first-line relatives. It is known that in children and adolescents whose close relatives (parents, grandparents, other family members) suffered from hypertension, an increase in blood pressure is observed three times more often than in their peers with heredity not burdened by hypertension. According to B.A. Namakanova (2003), the prevalence of hypertension among adolescents and young people with aggravated heredity is 25-65%. Similar data were also obtained by G.I. Nechaev et al. when examining 250 patients aged, whose parents suffered from arterial hypertension. Thus, hypertension was detected in 58.4% of the examined, elevated blood pressure - in 13.6%, in 24% of the study participants the blood pressure level was normal. The authors emphasize that none of the examined did not apply to medical institution on one's own.

When examining young people, one should take into account the high risk of developing arterial hypertension in patients with heredity burdened by hypertension.

Unlike adults, the value of blood pressure in children depends on their sex, age and height. At present, tables have been developed, on the basis of which it is possible to classify the values of blood pressure detected during the examination of children as normal, high normal or elevated. Such tables are used in pediatric practice (table). In children, normal values are considered to be those at which the level of systolic blood pressure (SBP) and diastolic blood pressure (DBP) is less than 90 percentiles (for a given age, height or sex); high normal blood pressure (or prehypertension) - SBP / DBP values equal to or greater than 90 percentiles, but less than 95 percentiles; AH - the level of SBP / DBP, exceeding 95 percentiles. The results of blood pressure measurements during three visits to the doctor with an interval of days should be taken into account. According to the level of blood pressure in children, two degrees of arterial hypertension are distinguished: the first degree (mild hypertension) is diagnosed with SBP / DBP values equal to or greater than 95 percentiles by less than 10 mm Hg. Art.; the second degree (moderate hypertension) - at the level of SBP / DBP exceeding the 95th percentile per 10 mm Hg. Art. or more.

Quite often, in children, adolescents and young people during psychoemotional stress, hyperreactivity of the sympathetic division of the autonomic nervous system and the cardiovascular system is observed, which leads to a temporary, sometimes significant increase in blood pressure. In normal situations, in these patients, blood pressure is within the age norm. In older age groups, hyperreactivity is less common and, as a rule, less pronounced.

A visit to the doctor for such persons is a kind of stressful situation and is accompanied by an increase in blood pressure. Hence the term "white coat hypertension". Such a reaction is not actually hypertension (as a disease), but, undoubtedly, it is a serious risk factor for its development and worsening of the patient's further prognosis (I.V. Leontieva, 2000, 2003). In patients with labile BP and white-coat hypertension, ambulatory 24-hour BP monitoring is recommended. This method will allow, first of all, to reduce the influence of the patient's psycho-emotional status on the results of measuring blood pressure, to level the "white coat hypertension" as much as possible, and to choose the optimal treatment tactics. At the same time, attention should be paid not only to the average daily SBP / DBP values, but also to the time index and the daily index, which characterize the time during which an increased BP value and the degree of decrease in SBP / DBP at night compared with the wakefulness period, SBP variability and DBP and the rate of their morning rise.

The presence of hypertension is indicated by a time index exceeding 25% of the total time of monitoring blood pressure. A time index of more than 50% indicates the presence of stable arterial hypertension. The nature of the change in blood pressure when performing physical activity. Bicycle ergometry is used to analyze the nature of the blood pressure reaction during exercise. For adolescents, a hypertensive hemodynamic reaction in response to physical activity is considered to be an increase in blood pressure to values exceeding 170/95 mm Hg. Art. According to I.V. Leontieva (2003), a hypertensive BP reaction is observed in 80% of patients with stable arterial hypertension and in 42% with labile AH. Moreover, in adolescents with stable hypertension, bicycle ergometry reveals an excessive increase not only in SBP, but also in diastolic blood pressure, peripheral vascular resistance (which is typical for a hypertensive response of blood pressure in response to exercise in adult patients with hypertension). Physical exercise in adolescent patients with stable hypertension, as well as in adult patients with AH, is accompanied by an increase in myocardial oxygen demand (as evidenced by large values and a greater increase with a double product load) and requires high energy consumption.

The course of juvenile arterial hypertension depends on many factors. It is believed that in the majority of adolescents with hypertension, normalization of blood pressure is possible in the future. Long-term dynamics of blood pressure in young people with initially elevated blood pressure has been studied in a number of studies. The article by J. Widimsky and R. Jandova (1987) presented data on a 33-year natural course of juvenile hypertension. The results of these researchers showed that 25% of the examined patients had normalization of blood pressure during the observation period. In another study (Yu.I. Rovda, 2005), stabilization of elevated blood pressure during three to seven years of observation was found in 46.5% of adolescents. G.P. Filippov et al. (2005) analyzed the three-year course of various types of hypertension (“white coat hypertension”, labile and stable) in adolescents on the background of non-drug therapy. Normalization of blood pressure during this period occurred only in one third of patients with initial "white coat hypertension", in 22.2% of the group it was transformed into labile hypertension. One third of patients with initially labile AH showed stabilization of elevated blood pressure. The most unfavorable course of the disease was noted in patients with initially stable arterial hypertension - almost 15% of them showed signs of disease progression, characterized by damage to target organs, while normalization of blood pressure was not noted in patients of this group during the observation process.

The presence of elevated blood pressure in adolescence can be considered as an important risk factor for hypertension in adults.

In addition, the results of the study indicate the expediency of distinguishing its forms in children and adolescents with hypertension - "white coat hypertension", labile and stable hypertension as having different prognostic value, and hence the features of observation and treatment. The importance of isolating these forms of hypertension is also noted by other authors dealing with the problem of hypertension in children and adolescents (I.V. Leontieva, 2000, 2003).

According to different authors, the risk factors for stabilization of arterial hypertension in adolescents include stable hypertension (especially in the presence of signs of target organ damage), heredity aggravated by arterial hypertension, overweight (obesity), physical inactivity, irrational diet, significant psycho-emotional overload (stress) , smoking, as well as a violation of the circadian rhythm of blood pressure (insufficient decrease in blood pressure during sleep, an increase in the variability and speed of the morning increase in SBP / DBP), atherogenic changes in the blood lipid spectrum, signs of endothelial dysfunction. Modifiable risk factors for hypertension include obesity, smoking, overconsumption table salt(important for salt-sensitive patients), sedentary lifestyle (physical inactivity), stress, the use of a number of drugs (non-steroidal anti-inflammatory drugs, oral contraceptives). The possibilities of influencing modifiable risk factors for arterial hypertension are covered in sufficient detail in the literature, so we will not dwell on them. Let us recall only a few of them.

Obesity is associated with the development of insulin resistance, hyperinsulinemia, disorders of carbohydrate and lipid metabolism, metabolic syndrome, activation of the sympathetic nervous system, progression of hypertension, damage to target organs, development coronary disease heart and cardiovascular complications.

According to V.V. Bekezina et al. (2007), 71.4% of children with metabolic syndrome (aged) show signs of endothelial dysfunction, and the development of vasoconstriction is recorded almost twice as often as in obese children. Therefore, the fight against obesity and the often accompanying metabolic syndrome is important in the primary and secondary prevention of arterial hypertension in young patients. Weight loss is accompanied by a decrease in blood pressure, an improvement in lipid profile and carbohydrate metabolism, a decrease in insulin resistance, and salt sensitivity. There is evidence of a decrease in the thickness of the walls of the left ventricle (S. Macmahon, 1989). Weight loss can be achieved through regular exercise and diet.

Patients with high blood pressure are shown dynamic exercises - walking or running for at least a minute, swimming, cycling, playing sports. Static exercises should be limited. As Hippocrates wrote, "gymnastics, physical exercises, walking should firmly enter the everyday life of everyone who wants to maintain working capacity, health, a full and joyful life. Nutrition should be complete in terms of vitamins, potassium, magnesium, calcium, unsaturated fats and include a sufficient amount of vegetables and fruits, fish, low-fat foods (DASH diet). You should control the calorie content of food. When choosing a diet in some cases (for example, with concomitant diseases gastrointestinal tract) should be consulted with a nutritionist. When applying non-drug therapy, one should remember the words of Hippocrates: "Neither satiety, nor hunger, and nothing else is good if it transgresses the measure of nature."

Indications for drug antihypertensive therapy in young patients correspond to generally accepted ones.

The appointment of antihypertensive drugs is indicated for patients of this category in the presence of signs of target organ damage, stable arterial hypertension of the II degree and the ineffectiveness of non-drug measures in 1 degree of hypertension. Drug treatment should be given concomitantly with recommendations for lifestyle changes in patients with severe hypertension, and those with a high or very high additional risk of complications, regardless of BP.

In grades 1 and 2 hypertension, the presence of signs of target organ damage or three or more risk factors, or metabolic syndrome, or diabetes mellitus indicates a high risk, and the presence of concomitant diseases of the cardiovascular system or kidneys indicates a very high additional risk. Drug therapy is prescribed in case of insufficient effect of non-drug measures.

The goal of treatment is to reduce the risk of complications and premature death. As you know, an increase in blood pressure for every 20/10 mm Hg. Art. doubles the risk of death from cardiovascular disease from a level of 115/75 mm Hg. Art.

According to the recommendations for the treatment of arterial hypertension, the target values are blood pressure less than 140/90 and 130/80 mm Hg. Art. respectively for the general population of patients with hypertension and for patients with concomitant diabetes, as well as those who have suffered an acute violation cerebral circulation or transient ischemic attack. There is evidence that in patients with nephropathy and high level proteinuria decrease in blood pressure less than 120/80 mm Hg. Art. may provide additional benefits.

Lowering and controlling (holding) blood pressure is essential to improve prognosis. However, when lowering blood pressure, it is necessary to take into account the specific situation. A sharp decrease in blood pressure should be avoided (it is known that a rapid decrease in blood pressure by more than 25% of the initial value is accompanied by a deterioration in the picture of the fundus, can lead to myocardial and cerebral ischemia, especially in patients with severe atherosclerotic vascular disease). It is almost impossible to achieve sufficient effectiveness of treatment without the active participation of the patient. When choosing a drug, one should take into account its effect on the risk of complications, the prognosis of arterial hypertension, damage to target organs, the nature of concomitant pathology, interaction with other drugs, the possibility of side effects. Today, there is a sufficient evidence base for the clinical efficacy of many antihypertensive drugs, based not only on the degree of BP reduction, but also on the effect on prognosis.

Treatment: Angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin II receptor blockers (ARBs) are most commonly used. The drugs of this group cause dilatation of arterial and venous vessels, which leads to a decrease in peripheral vascular resistance and preload; prevent the progression of dilatation of the left ventricle and contribute to a decrease in its cavity during the initial dilatation; limit the zone of necrosis and prevent the development of postinfarction myocardial remodeling; contribute to the regression of hypertensive hypertrophy of the left ventricle and vascular wall; do not affect heart rate and conduction; reduce myocardial oxygen demand; improve endothelial function; do not change or increase coronary and cerebral blood flow; cause dilatation of afferent and efferent arterioles of the glomeruli of the kidneys - reduce intraglomerular pressure; reduce albuminuria, increase renal blood flow (thus slowing down the progression of nephropathy and kidney failure); increase natriuresis; reduce adhesion and aggregation of platelets; contribute to the restoration of the function of the baroreflex mechanisms of the heart and blood vessels; increase tissue sensitivity to insulin; can positively affect the lipid spectrum of the blood; reduce initial hyperuricemia; increase the level of sensory activity and cognitive function of the brain.

Some ACE inhibitors have been shown to influence the prognosis of high-risk adults with hypertension. In this regard, the timely administration of this group of drugs is necessary in young patients, many of whom, as daily clinical practice shows, have a number of concomitant diseases that contribute to the occurrence of severe cardiovascular complications and worsening of the long-term prognosis. Preference should be given to modern, evidence-based ACE inhibitors such as ramipril and perindopril.

It is known that the use of ramipril in a double-blind placebo- controlled study HORE in high-risk adults reduced interventions for myocardial revascularization (by 15%), the incidence of acute cerebrovascular accident (by 32%), myocardial infarction (by 20%), cardiovascular death (by 26%), total mortality (by 16%). In the placebo-controlled SECURE study, ramipril slowed the progression of carotid atherosclerosis and reduced the thickness of the intima-media complex in patients at high risk of cardiovascular events, cardiovascular disease, or diabetes mellitus. Moreover, these effects were dose-dependent (a more pronounced effect was observed when using ramipril at a daily dose of 10 mg compared to 2.5 mg). Ramipril has proven effective in patients with acute myocardial infarction (AIRE study) and in patients with myocardial infarction and heart failure (AIREX study).

It should be noted that today in clinical practice there are more and more young patients with a persistent increase in blood pressure, requiring combined treatment. Even with relatively low blood pressure values, one should be attentive to such patients and, using all the modern possibilities of hardware diagnostics, try to establish the cause of its persistent increase. Such patients need to select the optimal combination of drugs as soon as possible, based on modern European recommendations. If we talk about combinations of ACE inhibitors with other drugs, then one of the most effective and safe is their combination with a thiazide diuretic, the effectiveness and safety of which has been proven in many authoritative clinical studies.

Adherence to treatment is a problem that always arises in the treatment of young patients. The increase in adherence to antihypertensive therapy in this case is facilitated by the prescription of long-acting drugs that can be taken once a day, as well as fixed combinations.

It should be borne in mind that none of the groups of antihypertensive drugs is devoid of side effects and contraindications for use in certain situations. When prescribing antihypertensive therapy to young patients, it should be remembered that a number of drugs should not be taken during pregnancy and during lactation. This applies primarily to ACE inhibitors and ARBs.

Timely detection of arterial hypertension in young people, diagnosis of its secondary forms and adequate treatment, including both non-drug methods and drug therapy, are of great medical and social importance, helping to reduce labor losses, improve the quality and increase the life expectancy of patients.

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Influence of antihypertensive agents of different pharmacological groups on blood pressure response under stress testing conditions Part I

E. A. Praskurnichiy, O.P. SHEVCHENKO, St. MAKAROVA, V.A. ZHUKOVA, S.A. SAVELYEVA

Russian State Medical University. Moscow, st. Ostrovityanova, 1

Effect of Antihypertensive Agents From Various Pharmacological Groups on Blood

Pressure Reaction During Stress-Testing. Part I. Comparative Characteristics of Medications, Exerting Effect of Sympathoadrenal Block

E.A. PRASKURNITCHY, O.P. SHEVTCHENKO, S.V. MAKAROVA, V.A. ZHUKOVA, S.A. SAVELIEVA

Russian State Medical University; ul. Ostrovityanova 1, Moscow, Russia

The level of blood pressure at rest and the data of 24-hour blood pressure monitoring (ABPM) are still the criteria for verifying arterial hypertension (AH), the main parameters characterizing the degree of its severity, as well as the most informative indicators reflecting the effectiveness of antihypertensive measures. At the same time, it has been repeatedly emphasized that the usual recording of blood pressure using the Korotkov method or under conditions of daily monitoring leaves a significant part of cases of increased blood pressure and uncontrolled course of hypertension that are stress-induced in nature beyond the diagnosed scope.

The pronounced dependence of the level of blood pressure on the degree of physical activity and psycho-emotional state of the patient is most clearly manifested in the onset of hypertension, but can be expressed at all stages of the progression of the disease. The significant variability of hemodynamic parameters present in these cases causes low reproducibility of the results of clinical measurements and ABPM. At the same time, exercise testing data reflecting the response of hemodynamics to the modeling of different stress exposure options make it possible to more accurately assess the feasibility and effectiveness of using various approaches to antihypertensive therapy. It is in this regard that there has been a trend towards a wider use of the results of stress testing in the clinical diagnostic process.

Since the 90s of the last century, the prognostic value of an increase in blood pressure in terms of stress testing has been widely discussed. However, a number of studies have produced mixed results. In particular, in the Framingham study, during a four-year follow-up, a hypertensive response of systolic BP to exercise in men was associated with an increased risk of developing AH, while this trend could not be traced in women. At the same time, the results of most studies indicate that a pronounced increase in blood pressure during exercise - more than 200/100 mm Hg. at a power level of 100 W during a bicycle ergometric (VEM-) test - is associated with a significant increase in the risk of damage to target organs, the development of cardiovascular complications and death.

Taking into account the prognostic value of the blood pressure level during exercise, as well as the possibility of its significant increase in these conditions with normal blood pressure at rest and with a standard assessment by the Korotkoff method, the identification of a hypertensive reaction during stress testing should be considered as an urgent task of diagnosis and monitoring. AH, and its elimination is an important tactical task of antihypertensive therapy.

In clinical practice, the response of blood pressure to physical activity is most widely studied during the VEM test. Some studies have demonstrated the high information content of the isometric load test. At the same time, a pronounced increase in blood pressure, recorded during various stress testing options, is associated with a high level of activation of neurohumoral systems, in particular, the sympathetic-adrenal system. Therefore, in situations of development of hypertensive reactions under conditions of stress testing, the most rational step towards optimizing therapy is to consider the possibility of using β-blockers and other agents that provide sympathetic-adrenal blockade.

The aim of the study was a comparative assessment of the effectiveness of β-blockers metoprolol and carvedilol and the agonist I 1 -imidazoline receptors moxonidine in reducing the stress-induced increase in blood pressure that occurs under conditions of static and dynamic physical activity.

The study included 81 patients aged 44 to 65 years with mild to moderate hypertension. Criteria for exclusion from the study included clinical manifestations ischemic heart disease, congestive heart failure, renal failure, diabetes mellitus, bronchial asthma, as well as an indication of a history of myocardial infarction, acute and transient cerebrovascular accident.

Patients were randomized to antihypertensive therapy groups. Representatives of the 1st group (n=32) received moxonidine at a dose of 0.2-0.4 mg/day, patients of the 2nd group (n=28) - metoprolol at a dose of 100-150 mg/day, patients of the 3rd group (n=21) - carvedilol (Acridilol®, Akrikhin) 50-75 mg/day. All drugs were administered as monotherapy; combination with other antihypertensive agents was not allowed.

All patients were followed up on an outpatient basis for 12 weeks, examinations were performed during 4 visits: visit 1 (randomization), visit 2 (week 2), visit 3 (week 6), visit 4 visit (12th week). The start of active treatment was preceded by a two-week control period, during which the previously prescribed antihypertensive therapy was cancelled.

At baseline and at the end of the 12th week, the patients underwent examination, which included the collection of anamnestic data, an objective examination, ABPM, VEM test, assessment of heart rate variability (HRV). During other visits, clinical monitoring of blood pressure was performed, subjective and objective symptoms were assessed, as well as patient adherence to treatment.

In order to calculate the reference values of the parameters of cardiovascular testing, a control group of practically healthy individuals was examined, consisting of 28 people aged 27-60 years (average 51.4±7.2 years) with clinical BP (BPcl.) less than 140/90 mm. rt. Art., average daily blood pressure less than 125/80 mm. rt. Art., as well as with a normotensive type of blood pressure reaction under the conditions of the VEM test.

ADcl. was measured by auscultation according to the Korotkov method, in the position of the subject sitting after a 5-minute rest. ABPM was performed using the CardioTens-01 device (Mediteck, Hungary) on weekdays for 24±0.5 hours, with an interval of 15 minutes during the day, 30 minutes at night, and 10 minutes in the early morning hours. All patients kept an individual diary of well-being, physical and mental activity, time and quality of sleep. We analyzed such parameters as average daily, average daily, average night levels of systolic BP (SBP) and diastolic BP (DBP), as well as pressure load indicators (time index and area index of hypertension), BP variability and daily index. The level of average daily blood pressure is 130 mm Hg. or more for CAD and 80 mmHg. or more for DBP was considered elevated.

An isometric test was carried out as follows. The maximum force was determined using a dynamometer. right hand patient. Then, for 3 minutes, the patient squeezed the dynamometer with a force of 30% of the maximum. Heart rate (HR) and blood pressure were recorded immediately before the test and at the end of the 3rd minute of dynamometer compression. Evaluated parameters: maximum SBP, DAP, HR measured at the end of the 3rd minute of the test, increase in SBP, DBP, HR - the difference between the maximum SBP, DBP, HR and initial values.

The VEM test was performed on an ERGOLINE D bicycle ergometer (Bitz, Germany) in the position of the subject lying on his back, in the morning after a light breakfast using the method of stepwise increasing load. The test was started with a load of 25 W, the power of which was increased by 25 W with an interval of 3 min. BP and heart rate were recorded at baseline and then at 1-minute intervals during exercise and at every minute of the recovery period. ECG monitoring in 12 conventional leads was carried out during the entire test, registration - at the 3rd minute of each stage of the load. An increase in blood pressure of more than 200/100 mm Hg was considered the criterion for a hypertensive reaction during the exercise test. with a VEM test against a load of 100 W and an excess of blood pressure of more than 140/90 mm Hg. at the 5th minute of the recovery period.

HRV was studied by analyzing ECG recordings recorded for 5 minutes using the VNS-Rhythm Neurosoft equipment (Russia) in the morning at rest 15 minutes after the patient was in the supine position. HRV was analyzed using statistical methods (SDNN, ms - standard deviation from the average duration of all sinus R-R intervals; RMSSD, ms - root-mean-square difference between the duration of adjacent sinus R-R intervals; pNN50, % - proportion of adjacent R-R intervals that differ by more than 50 ms obtained over the entire recording period) and spectral analysis (total power of the spectrum - T P, high-frequency component of the spectrum - HF, low-frequency component of the spectrum - L F, very low-frequency component of the spectrum - VLF, relative value of HF%, LF%, VLF% of the total spectrum power, index of vago-sympathetic interaction - LF/HF).

When conducting an active orthostatic test, the patient, after a 15-minute rest in a horizontal position with a low headboard, on command, without delay, took a vertical position and stood without undue stress for 6 minutes. The level of blood pressure and heart rate was measured immediately before the orthostatic test at rest, immediately after the transition from a horizontal to a vertical position, at the end of the 1st, 3rd and 6th minutes of taking a standing position. ECG was recorded throughout the entire test for 6 min.

Statistical analysis was performed using the Excel 7.0 software package and BIOSTAT using the recommended criteria. Differences were considered significant at p. Results

Initially, the results of treatment with the I 1 -imidazoline receptor agonist moxonidine, the β1-selective blocker metoprolol, and the non-selective β-blocker with α1-adrenergic blockade properties carvedilol were analyzed. The use of these drugs in medium doses was characterized by comparable antihypertensive efficacy. A negative chronotropic effect was noted only in groups of individuals who received β-blockers metoprolol and carvedilol. The dynamics of blood pressure and heart rate according to clinical measurements is presented in Table. 1. The number of patients who managed to achieve a decrease in blood pressure less than 140/90 mm Hg in the groups of moxonidine, metoprolol and carvedilol did not differ significantly and amounted to 59%, 64% and 69%, respectively.

Table 1. Dynamics of blood pressure and heart rate during therapy according to clinical measurements

Note: SADcl. - clinical systolic blood pressure, DBPcl. - clinical diastolic blood pressure, heart rate. - clinical heart rate, * - p

According to the results of the dynamic assessment of ABPM indicators, the decrease in SBP was approximately equally pronounced against the background of the use of all compared drugs and was due to their predominant effect on the average daily level of SBP (Table 2). There was no significant increase in blood pressure at night before the appointment of therapy, and the antihypertensive effect of drugs at night was minimal. At the same time, carvedilol therapy was accompanied by a more pronounced decrease in DBP than with the appointment of moxonidine and metoprolol, although it was in the 3rd group that this indicator was significantly changed initially. A negative chronotropic effect was recorded only against the background of the use of β-blockers.

Table 2. Dynamics of indicators of daily monitoring of blood pressure against the background of ongoing therapy

Note: SBP - systolic blood pressure, DBP - diastolic blood pressure, HR - heart rate, *-p

Taking into account the task set before the study (assessment of the effect of the studied drugs on the stress-induced increase in blood pressure), an analysis was made of the dynamics of hemodynamic parameters recorded during exercise testing during therapy with moxonidine, metoprolol, and carvedilol. The results of the isometric exercise test generally reflected a comparable effect of the compared drugs in suppressing the hypertensive response (Fig. 1).

Rice. 1. Dynamics during therapy of maximum blood pressure, registered during the isometric test.

SBP - systolic blood pressure; DBP - diastolic blood pressure. *-p

Meanwhile, of particular interest is the analysis of the dynamics of hemodynamic parameters recorded during the VEM test (Table 3). It is noteworthy that, with comparable antihypertensive efficacy in relation to the effect on blood pressure at rest, the studied drugs correct blood pressure to varying degrees during exercise. In particular, the I1-imidazoline receptor agonist moxonidine did not significantly affect the hypertensive response that occurs during the HEM test. Blockers of β-adrenergic receptors, on the contrary, significantly reduce the maximum and SBP, and DBP, which are achieved when performing this variant of stress testing. Moreover, 85% of patients in the metoprolol group and 89% of patients in the carvedilol group eliminated the hypertensive type of response to exercise.

Table 3. Dynamics of hemodynamic parameters recorded during the VEM test

Note: VEM - bicycle ergometric, SBP - systolic blood pressure, DBP - diastolic blood pressure, HR - heart rate, * - p

The decrease in maximum blood pressure during a test with dynamic physical activity under the influence of therapy with β-adrenergic blockers metoprolol and carvedilol (Fig. 2) is ensured due to a decrease not only in blood pressure recorded immediately before testing, but also in the degree of increase in both blood pressure and heart rate under conditions of increasing intensity dynamic type of physical activity. The I 1 -imidazoline receptor agonist moxonidine does not significantly affect these parameters.

Rice. Fig. 2. Dynamics of the increase in blood pressure against the background of therapy, recorded during the VEM test when the load power reaches 100 W

VEM - bicycle ergometric; SBP - systolic blood pressure, DBP - diastolic blood pressure, * -p

When evaluating the hemodynamic parameters recorded upon reaching a load power of 100 W, it was shown that carvedilol significantly more than metoprolol causes a decrease in maximum blood pressure and an increase in blood pressure at the height of the load, and this applies to both SBP and DBP.

An analysis of the effect of moxonidine, metoprolol, and carvedilol on HRV parameters made it possible to identify diametrically opposite trends characterizing these groups of antihypertensive drugs. Both β-blockers increased the total power of the spectrum, pNN 50%; metoprolol significantly increased SDNN, which generally reflects an increase in HRV. Metoprolol, to a significantly greater extent than carvedilol, caused a shift in the sympathovagal ratio towards the predominance of vagal influence, although the changes in this indicator were unidirectional and significant in both groups. The use of moxonidine was accompanied by a decrease in the total spectrum power, the RMSSD indicator, reflecting the trend towards a decrease in HRV.

The effect of drugs on the vegetative provision of vascular tone was also studied during the orthostatic test. The nature of fluctuations in hemodynamic parameters during therapy with moxonidine and metoprolol was close to physiological, while during the use of carvedilol, there was no increase in SBP recorded at the time of transition to a vertical position. At the same time, under these conditions, no pronounced decrease in blood pressure was noted, while in the patients we observed, such hemodynamic changes were not accompanied by clinically significant manifestations. In addition, when using β-blockers during the orthostatic test, a significant decrease in heart rate was recorded, while moxonidine did not significantly affect this indicator.

Rice. 3. Dynamics of heart rate recorded during the orthostatic test

HR - heart rate, * -p

Rice. 4. Dynamics of maximum SBP recorded during the orthostatic test

SBP - systolic blood pressure. The difference in the values of the indicator against the background of therapy with all drugs with the initial data is significant (p

The study of changes in hemodynamic parameters in response to physical activity and the influence of various antihypertensive drugs on them is of key importance for the choice drug treatment patients with hypertension. The results of the analysis of the characteristics of the response of the circulatory system in these conditions open up possibilities for optimizing antihypertensive therapy by including drugs with the most favorable hemodynamic characteristics in this clinical situation. At the same time, it should be emphasized that recommendations based on the results of stress testing to change the structure of antihypertensive treatment should not conflict with its fundamental principles, namely, the focus on achieving the target level of blood pressure.

In the light of the above, the results of this study are of great importance, indicating a comparable antihypertensive efficacy of the I 1 -imidazoline receptor agonist moxonidine and β-blockers metoprolol and carvedilol according to clinical measurements of blood pressure. Monotherapy based on the use of these drugs, in a significant proportion of cases of non-severe hypertension, allows you to achieve target blood pressure values.

Studied within this study drugs are characterized by different mechanisms of suppression of sympathetic-adrenal activity. I 1 -imidazoline receptor agonists are drugs of the central type of action, highly selective for I 1 -imidazoline receptors found in the nuclei of the reticular formation, rostral-ventrolateral region medulla oblongata(subtype 1). A decrease in blood pressure and a decrease in heart rate are associated with a sympatholytic effect, which is due to the activation of I 1 -imidazoline receptors. The effect on the sympathetic-adrenal system of β-blockers is in competitive antagonism with catecholamines in relation to β-adrenergic receptors. Currently, third-generation β-blockers with additional vasodilatory properties are widely used in cardiology. In particular, carvedilol, being a combined β1- and β2-adrenergic blocker and providing a1-adrenergic blocking effect, provides a more pronounced vasodilating effect. Obviously, it was the additional vasodilatory effect of the drug that provided it with an advantage over other drugs in our study, in which, according to the results of ABPM, carvedilol was superior to comparators in terms of the effect on the average daily level of DBP.

It was assumed that the known features of the hemodynamic profile of the compared antihypertensive drugs would be most demonstratively manifested during exercise testing.

At the same time, during the test with an isometric load, no advantages of any drug in terms of the effect on blood pressure and heart rate were noted. As is known, isometric muscle tension during static load is accompanied by an inadequate increase in blood pressure and an increase in heart rate. Endothelial dysfunction is considered as a possible mechanism that determines the similar nature of hemodynamic disorders. The corrective effect of antihypertensive drugs, including sympatholytics, on endothelial dysfunction in AH has been demonstrated in many studies and, apparently, plays an important role in suppressing the hypertensive response induced by static exercise.

In contrast to the isometric test, stress testing using a dynamic type of physical activity revealed significant differences in the hemodynamic effects of the compared drugs. The superiority of the β-adrenoblockers metoprolol and carvedilol in suppressing the hypertensive response to exercise over the I 1 -imidazoline receptor agonist moxonidine was evident. At the same time, β-blockers effectively reduced the stress-induced increase in both SBP and DBP. Therefore, at least in the aspect of correcting hypertensive reactions induced by dynamic exercise, agonists of I 1 -imidazoline receptors, despite the available information about the effect of sympathetic-adrenal blockade, cannot be considered as an alternative to β-blockers.

The key role of activation of neurohumoral systems, in particular the sympathetic-adrenal system, in the pathogenesis of stress-induced increase in blood pressure is well known. In this regard, it would be logical to assume that the effect of I 1 -imidazoline receptor agonists and β-blockers on the functional status of the sympathetic and parasympathetic parts of the autonomic nervous system can fundamentally differ, and that these differences can play an important role in the modification of stress-induced hypertensive reactions to background of therapy with these drugs.

The results of assessing the effect of moxonidine, metoprolol and carvedilol on HRV parameters - one of the most informative and practical methods for assessing the state of the autonomic support of cardiovascular processes - confirm the above assumption about the existence of fundamental differences in the effects of these drugs in relation to the sympatho-vagal balance.

Comparing the features of the influence of representatives of various classes of antihypertensive drugs on the vegetative status with the nature of the modification of stress-induced hypertensive reactions, we can come to the following conclusions. A decrease in the severity of stress-induced hypertensive response under the influence of β-blockers metoprolol and carvedilol is associated with their optimizing effect on the main parameters of HRV, including the sympathovagal ratio (LF / HF), which ultimately serves as a manifestation of sympathetic-adrenal blockade when using these drugs. Against the background of a pronounced suppression of the activity of the sympathetic-adrenal system, the studied β-blockers not only eliminated the hypertensive type of reaction in response to physical activity, but also decreased the increase in blood pressure during exercise. The absence of an effect on the stress-induced increase in blood pressure under conditions of dynamic load against the background of moxonidine therapy was stated along with signs of an increase in heart rhythm rigidity, reflecting an increase in the contribution of the sympathetic division of the autonomic nervous system to the control of heart activity.

When determining a β-blocker as the optimal drug for suppressing stress-induced hypertensive response caused by dynamic exercise, one should take into account the large number of representatives of this pharmacological group on present stage and a wide variety of pharmacological properties. Discussion about clinical significance certain characteristics of a β-adrenergic blocker is not the subject of this publication. At the same time, it should be noted that with the advent of new generation β-adrenergic receptor blockers, which give an additional vasodilating effect, the possibilities of antihypertensive therapy based on the use of drugs of this class have significantly expanded.

The question of the advantages of β-blockers with additional vasodilating properties over the “classical” β1 -selective adrenoblockers is considered in this paper in the context of assessing their comparative effectiveness in limiting the stress-induced hypertensive response in people with hypertension. In general, the results of the VEM test indicated the benefits of the β- and α1-blocker carvedilol in terms of suppression of the hypertensive reaction that occurs under the conditions of this stress testing variant. Therefore, under conditions of clinically effective β-adrenergic blockade, the vasodilation effect, due in this case to the anti-α1-adrenergic action, provides the drug with additional opportunities to suppress the hypertensive response during exercise testing.

Along with the achievement of a pronounced antihypertensive effect, an important condition for the pharmacotherapy of hypertension is the exclusion of orthostatic hypotensive reactions fraught with adverse consequences against the background of adequate dosages of drugs. In order to clarify the degree of risk of such episodes, as well as to characterize the features of autonomic regulation that play an important role in their development, a dynamic analysis of the results of the orthostatic test was carried out.

During the transition from a horizontal position to a vertical position, blood flow to the right parts of the heart decreases, and the central blood volume decreases by an average of 20%, and the cardiac output - by 1-2.7 l / min. Then, during the first 15 contractions of the heart after moving to a vertical position, the heart rate increases due to a decrease in the tone of the vagus, and after about 20-30 seconds, the parasympathetic tone is restored and reaches its greatest degree (relative bradycardia is recorded). Approximately 1-2 minutes after the transition from a horizontal to a vertical position, catecholamines are released and the tone of the sympathetic division of the autonomic nervous system increases, in connection with which an increase in heart rate and peripheral vascular resistance is noted. After that, the renin-angiotensin mechanism of hemodynamic control is activated.

Preservation of the nature (close to physiological) of hemodynamic changes recorded during the orthostatic test during therapy with moxonidine and metoprolol indicates the relative safety of these drugs in relation to the development of orthostatic hypotensive reactions. This property of antihypertensive drugs is of great importance when choosing drugs that are acceptable for inclusion in the therapy of persons with a low adaptive potential of blood circulation.

In this regard, the data obtained in the carvedilol treatment group are of particular interest. In general, the absence of a pronounced increase in systolic blood pressure, apparently, should be considered as a manifestation of a pronounced vasodilating effect of this drug, which is probably due to its α1-adrenergic blocking effect. In turn, the β-adrenergic blocking component in the pharmacological profile of carvedilol largely eliminates the described side effects. Nevertheless, we consider it necessary to point out the undesirability of prescribing this drug to patients who have a tendency to develop orthostatic hypotensive reactions during functional tests.

Thus, the results of the study made it possible to demonstrate that, with comparable antihypertensive efficacy according to casual measurements and ABPM, antihypertensive drugs of different pharmacological groups have different ability to suppress the stress-induced hypertensive response that occurs during stress testing.

Drugs that have the properties of sympathetic-adrenal blockade - the agonist of I 1 -imidazoline receptors moxonidine, β-blockers metoprolol and carvedilol - reduce the severity of the hypertensive reaction recorded during an isometric stress test.
In contrast to the I 1 -imidazoline receptor agonist moxonidine, at doses that provide a comparable antihypertensive effect, β-blockers carvedilol and metoprolol cause suppression of the stress-induced hypertensive response that occurs in a dynamic exercise test.
A decrease in the increase in blood pressure recorded during a bicycle test during therapy with β-blockers is associated with an increase in heart rate variability, while the absence of an effect on the stress-induced increase in blood pressure under these conditions when prescribing moxonidine, on the contrary, is combined with signs of a decrease in heart rate variability, noted while taking this drug.
With comparable antihypertensive efficacy, according to the data of daily monitoring of blood pressure and casual measurements of blood pressure, the non-selective β-blocker with the property of a1-adrenergic blockade carvedilol (Acridilol®) has a corrective ability to reduce the hypertensive response under stress testing conditions higher than selective β1- adrenoblocker metoprolol.
The I 1 -imidazoline receptor agonist moxonidine, β-blockers metoprolol and carvedilol, when taken regularly, do not provoke the development of postural phenomena in persons who do not have hypotensive conditions prior to the appointment of these drugs during an orthostatic test.

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Distinguish five types of reactions cardiovascular system on load:

1. With a good functional state of the cardiovascular system, normotonic reaction, which is characterized by an increase in heart rate by 30-50%, a distinct increase in systolic blood pressure by 10-35 mm Hg. Art. and some decrease (by 4-10 mm Hg) in diastolic blood pressure, the recovery period is 2-3 minutes. The noted type of reaction indicates the adequacy of the body to physical activity.

In addition to the normotonic reaction, atypical reactions may occur during functional tests.

2. Hypotonic or asthenic.

With this reaction, there is a significant increase in heart rate (more than 130%), a slight increase in systolic blood pressure and a slight decrease in diastolic blood pressure; the reaction is characterized by a slow recovery of the pulse and pressure to the initial values (up to 5-10 minutes). It is observed in functional diseases of the heart and lungs. In children with low physical fitness, such a reaction can be considered a variant of the norm.

3. Hypertensive reaction.

It is characterized by a sharp increase in heart rate (more than 130%), a significant increase in systolic blood pressure (up to 200 mm Hg), a moderate increase in diastolic blood pressure. The recovery period is significantly lengthened. A similar reaction occurs with arterial hypertension.

4. Dystonic.

With this variant, there is a significant increase in systolic blood pressure with a sharp simultaneous decrease in diastolic blood pressure, which often drops to zero, that is, an “endless tone phenomenon” is obtained. The pulse is sharply accelerated, and the recovery period is longer, up to 6-7 minutes. Such a reaction in schoolchildren may be associated with a state of overtraining, vegetative neuroses, recently infectious diseases. In athletes, subject to a rapid recovery of diastolic blood pressure within 1 minute, it is considered an indicator of high physical fitness. In the case when the restoration of diastolic blood pressure is delayed up to 2-3 minutes, the student must be referred for examination to a cardiologist.

5. stepped.

With this type of reaction, systolic blood pressure at the 2nd-3rd minute of the recovery period is higher than at the 1st minute, diastolic blood pressure changes slightly, mainly downward against the background of a sharp increase in heart rate. Such a reaction is associated with a functional inferiority of the mechanisms of regulation of the activity of the cardiovascular system, indicating an insufficient adaptive ability of the cardiovascular system to physical exertion.

With atypical reactions of the cardiovascular system to physical activity, ECG studies and consultation with a cardiologist are necessary.

Thus, when assessing the degree of adaptation of the cardiovascular system to physical activity, the following are noted:

a) good. It is observed with a normotonic type of reaction with a recovery period of up to 5 minutes;

b) satisfactory - the shifts in the pulse and blood pressure exceed the normative ones, but their parallelism remains, the recovery period is extended to 7 minutes;

c) unsatisfactory - the manifestation of atypical reactions to physical activity (especially hypertonic and dystonic types) is characteristic. The recovery period is extended to 12 minutes.

When assessing the response of the cardiovascular system to physical activity, the leading role should be given to the recovery period, analyzing the activity and nature of the recovery of the pulse and blood pressure.

Hypertensive reaction hell to the load. Physiological changes during exercise

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