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ѕробелы в доказательных данных и необходимость дальнейших исследований





 

≈сли проанализировать доказательные данные, на основе которых создавались рекомендации 2013 г. по ј√, становитс€ очевидным, что несколько терапевтических проблем продолжаютс€ оставатьс€ открытыми и нуждаютс€ в дальнейшем изучении:

1. Ќужно ли назначать медикаментозную антигипертензивную терапию всем больным с ј√ 1 степени и низким и средним сердечно-сосудистым риском?

2. Ќужно ли назначать медикаментозную антигипертензивную терапию больным старческого возраста с уровнем —јƒ от 140 до 160 мм рт.ст.?

3. Ќужно ли назначать медикаментозную терапию пациентам с Ђгипертонией белого халатаї? ћожно ли дифференцировать пациентов с этим состо€нием, нуждающихс€ и не нуждающихс€ в лечении?

4. Ќужно ли начинать медикаментозную антигипертензивную терапию в диапазоне высокого нормального јƒ и если да, то каким больным?

5.  аковы оптимальные офисные значени€ јƒ (т.е., наиболее безопасные и обеспечивающие наилучшую протекцию), которых нужно достигать на фоне лечени€ у пациентов с различными демографическими и клиническими характеристиками?

6. »меют ли подходы к лечению, основанные на контроле внеофисного јƒ, преимущество (в виде снижени€ клинической заболеваемости и смертности, применени€ меньшего числа препаратов, меньшего числа побочных эффектов) перед подходами, основанными на традиционном офисном контроле јƒ?

7.  аковы оптимальные значени€ внеофисного (домашнего и амбулаторного) јƒ, которых нужно достигать на фоне лечени€, и должны ли целевые значени€ у больных ј√ высокого риска быть выше или ниже?

8. ћожет ли учет значений центрального јƒ улучшить прогнозирование сердечно-сосудистых событий у нелеченых и леченых больных ј√?

9. »меют ли инвазивные процедуры дл€ лечени€ резистентной ј√ преимущества перед наилучшей медикаментозной терапией и обеспечивают ли они длительный контроль јƒ и снижение заболеваемости и смертности?

10. явл€етс€ ли динамика бессимптомного поражени€ органов-мишеней, обусловленна€ лечением, предиктором исходов?  акие параметры или кака€ комбинаци€ параметров наиболее ценны?



11. ћогут ли изменени€ образа жизни, которые снижают јƒ, уменьшить также число осложнений и смертность у больных ј√?

12. —пособствует ли уменьшение суточной вариабельности јƒ на фоне лечени€ лучшему протективному действию антигипертензивной терапии на сердечно-сосудистую систему?

13. ћожет ли снижение јƒ существенно уменьшить сердечно-сосудистый риск при резистентной ј√?

’от€ Ђзолотым стандартомї разрешени€ терапевтических проблем остаютс€ – », точно также €сно, что было бы неразумно ожидать, что на все эти вопросы можно в предвидимом будущем действительно получить ответ с помощью – ». –ешение некоторых из этих вопросов, например, об уменьшении сердечно-сосудистой заболеваемости и смертности при лечении больных ј√ 1 степени с низким риском сердечно-сосудистых заболеваний или о снижении числа сердечно-сосудистых событий при изменении образа жизни, потребовало бы исследований на многих тыс€чах пациентов в течение очень длительного времени; кроме того, такие исследовани€ вызвали бы р€д этических проблем. ƒругие вопросы, такие как польза лекарственной терапии при Ђгипертонии белого халатаї или дополнительна€ прогностическа€ сила центрального јƒ, по сравнению с периферическим, могут потребовать больших усилий от исследований при скромной ожидаемой пользе. ѕредставл€етс€ целесообразным, по крайней мере, в ближайшие годы, фокусировать – » на важных и легче решаемых вопросах, таких как оптимальные целевые значени€ јƒ на фоне лечени€; значени€ јƒ, при которых нужно назначать терапию и целевые значени€ у больных ј√ пожилого и старческого возраста; снижение заболеваемости и смертности при использовании новых подходов к лечению резистентной ј√ и возможна€ польза от лечени€ пациентов из группы высокого риска, но с высоким нормальным јƒ.   решению других важных вопросов, например, о прогностическом значении внеофисного јƒ и поражени€ органов-мишеней, более реально можно подойти, если добавить оценку этих показателей в дизайн некоторых – », которые планируютс€ в ближайшем будущем.


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