In recent years, the term “high risk patients” has become very popular. A number of publications are devoted to high-risk patients, and Russian and international CVD congresses often hold symposia on this topic. However, there is no common understanding of this term. The high-risk category includes patients of varying severity. For example, in the European guidelines for the prevention of CVD in clinical practice (2007), patients with high clinical risk include both patients with any clinical manifestations of atherosclerosis (coronary, cerebral, peripheral), and those without clinical signs of atherosclerosis. but there is a high risk of its development [91]. In the latest European and Russian recommendations on the diagnosis and treatment of hypertension, high-risk patients include those who have 3 risk factors,MS or sub-clinical lesions of target organs. If hypertensive patients have associated CVD, then they are classified as “very high risk”.
In order to objectively approach the definition of high-risk patients, it is necessary to recall the well-known concepts of the risk factors. There are three strategies for the prevention of CVDs that complement each other and are aimed at minimizing the risk of complications: a population strategy, a high risk strategy and secondary prevention.
The population strategy aims to influence those lifestyle and environmental factors that increase the risk of CVD development among the entire population. A high risk strategy involves identifying people at high risk of developing CVD among patients without clinical manifestations of atherosclerosis and implementing multifactorial prophylaxis. In essence, a high-risk strategy is the same as primary prevention. Thus, the key feature of high-risk patients is the absence of clinical manifestations of atherosclerosis. As for patients with clinical manifestations of atherosclerosis (coronary, cerebral, peripheral vessels), they are the object of secondary prevention, which is aimed at preventing the progression of CVD.
The relevance of a high-risk strategy is determined by the fact that high-risk patients in the total mass of cardiac patients are the overwhelming majority, therefore the main share of complications falls on this group. In this regard, timely identification of patients with high risk and the correct strategy for their management can significantly reduce the incidence of complications. If we talk about the strategy of managing high-risk patients, in recent years there have been major changes, and the importance of the drug component of managing such individuals has increased. Essentially, the principle of management of high-risk patients is the same as patients who already have CVD. For example, if you analyze the treatment strategy patients with stable angina pectoris, it can be noted that it consists of two aspects – the use of drugs to eliminate symptoms (nitrates) and the appointment of means to improve the prognosis (beta-blockers, statins, anti-aggregates).
For high-risk hypertensive patients, a modern management strategy will look similar: use of antihypertensive drugs (to lower blood pressure and improve patient well-being) and administer statins and antiplatelet agents to improve the prognosis. However, the problem of high-risk patients is that, unlike very high-risk patients, they are less motivated for treatment (risk factors do not “hurt”). Therefore, there is a gap between the need for intensive medical treatment and the weak motivation of these patients to treatment. However, this is another problem, and the physician should make every effort to guide these patients in terms of current requirements.
Let us dwell on the most important sections of the drug treatment of high-risk patients.
Antihypertensive therapy
The following chapter describes the main goals and objectives of antihypertensive therapy. Here we only note that high-risk patients, as well as very high-risk patients, need starting combination therapy, that is, quite intensive antihypertensive therapy at the initial stage of treatment.
Starting combination therapy is the key to the rapid achievement of target blood pressure in the majority of patients and significantly improves adherence to therapy. In actual clinical practice, patients with hypertension, most of whom are not motivated for treatment, need to quickly prove the effectiveness of the treatment chosen. Any delay in time associated with changing the dose, drug, or combination of drugs, undermines the patient’s confidence in the treatment and reduces adherence to it.