Пробелы в доказательных данных и необходимость дальнейших исследований
Если проанализировать доказательные данные, на основе которых создавались рекомендации 2013 г. по АГ, становится очевидным, что несколько терапевтических проблем продолжаются оставаться открытыми и нуждаются в дальнейшем изучении:
1. Нужно ли назначать медикаментозную антигипертензивную терапию всем больным с АГ 1 степени и низким и средним сердечно-сосудистым риском?
2. Нужно ли назначать медикаментозную антигипертензивную терапию больным старческого возраста с уровнем САД от 140 до 160 мм рт.ст.?
3. Нужно ли назначать медикаментозную терапию пациентам с «гипертонией белого халата»? Можно ли дифференцировать пациентов с этим состоянием, нуждающихся и не нуждающихся в лечении?
4. Нужно ли начинать медикаментозную антигипертензивную терапию в диапазоне высокого нормального АД и если да, то каким больным?
5. Каковы оптимальные офисные значения АД (т.е., наиболее безопасные и обеспечивающие наилучшую протекцию), которых нужно достигать на фоне лечения у пациентов с различными демографическими и клиническими характеристиками?
6. Имеют ли подходы к лечению, основанные на контроле внеофисного АД, преимущество (в виде снижения клинической заболеваемости и смертности, применения меньшего числа препаратов, меньшего числа побочных эффектов) перед подходами, основанными на традиционном офисном контроле АД?
7. Каковы оптимальные значения внеофисного (домашнего и амбулаторного) АД, которых нужно достигать на фоне лечения, и должны ли целевые значения у больных АГ высокого риска быть выше или ниже?
8. Может ли учет значений центрального АД улучшить прогнозирование сердечно-сосудистых событий у нелеченых и леченых больных АГ?
9. Имеют ли инвазивные процедуры для лечения резистентной АГ преимущества перед наилучшей медикаментозной терапией и обеспечивают ли они длительный контроль АД и снижение заболеваемости и смертности?
10. Является ли динамика бессимптомного поражения органов-мишеней, обусловленная лечением, предиктором исходов? Какие параметры или какая комбинация параметров наиболее ценны?
11. Могут ли изменения образа жизни, которые снижают АД, уменьшить также число осложнений и смертность у больных АГ?
12. Способствует ли уменьшение суточной вариабельности АД на фоне лечения лучшему протективному действию антигипертензивной терапии на сердечно-сосудистую систему?
13. Может ли снижение АД существенно уменьшить сердечно-сосудистый риск при резистентной АГ?
Хотя «золотым стандартом» разрешения терапевтических проблем остаются РКИ, точно также ясно, что было бы неразумно ожидать, что на все эти вопросы можно в предвидимом будущем действительно получить ответ с помощью РКИ. Решение некоторых из этих вопросов, например, об уменьшении сердечно-сосудистой заболеваемости и смертности при лечении больных АГ 1 степени с низким риском сердечно-сосудистых заболеваний или о снижении числа сердечно-сосудистых событий при изменении образа жизни, потребовало бы исследований на многих тысячах пациентов в течение очень длительного времени; кроме того, такие исследования вызвали бы ряд этических проблем. Другие вопросы, такие как польза лекарственной терапии при «гипертонии белого халата» или дополнительная прогностическая сила центрального АД, по сравнению с периферическим, могут потребовать больших усилий от исследований при скромной ожидаемой пользе. Представляется целесообразным, по крайней мере, в ближайшие годы, фокусировать РКИ на важных и легче решаемых вопросах, таких как оптимальные целевые значения АД на фоне лечения; значения АД, при которых нужно назначать терапию и целевые значения у больных АГ пожилого и старческого возраста; снижение заболеваемости и смертности при использовании новых подходов к лечению резистентной АГ и возможная польза от лечения пациентов из группы высокого риска, но с высоким нормальным АД. К решению других важных вопросов, например, о прогностическом значении внеофисного АД и поражения органов-мишеней, более реально можно подойти, если добавить оценку этих показателей в дизайн некоторых РКИ, которые планируются в ближайшем будущем.
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