Arterial hypertension is a pathological or physiological predisposition to a sudden or gradual increase in both the systolic and diastolic components of intravascular blood pressure, which occurs as an independent nosological unit or as a manifestation of another pathology present in the patient.
According to global statistics, the epidemiological situation regarding the incidence of arterial hypertension is unfavorable, because the percentage of this pathology in the structure of cardiac diseases reaches 30%.There is a clear correlation between the increased risk of developing signs and consequences of arterial hypertension with increasing age of patients, and therefore the main category of increased risk is mature and elderly people.
Causes of arterial hypertension
The appearance of signs of increased blood pressure in a patient can occur against the background of existing chronic diseases, and then we are talking about the secondary or symptomatic version of arterial hypertension.In cases where arterial hypertension is of a primary nature, and even after a comprehensive examination of the patient it is not possible to determine the cause that causes an increase in intravascular blood pressure, the term "hypertension" should be used, which is an independent nosological form.
Primary arterial hypertension is observed in almost 90% of cases of existing elevated blood pressure, and the polyetiology of the development of this pathological condition is currently being considered.Thus, there are immutable risk factors for arterial hypertension, which cannot be avoided (gender, genetic determination and age), however, these provoking factors are not dominant in the occurrence of severe arterial hypertension.The development of signs of primary arterial hypertension is largely influenced by a person's lifestyle (unbalanced diet, bad habits, inactivity, psycho-emotional instability).Taken together, all the mentioned provoking factors sooner or later create favorable conditions for the pathogenetic development of arterial hypertension.
Currently, many pathogenetic theories of the development of essential arterial hypertension are being considered, although these hypotheses have no influence on patient management tactics and determination of the scope of therapeutic measures.To a greater extent, the etiopathogenesis of the development of secondary arterial hypertension should be taken into account, because without eliminating the etiological factor that causes an increase in blood pressure, in this case, positive treatment results should not be expected.
Thus, in the renovascular variant of symptomatic arterial hypertension, the main pathogenetic link is renal artery stenosis, which occurs due to atherosclerotic lesions or fibromuscular dysplasia.An extremely rare etiologic factor affecting the renal arteries is systemic vasculitis.The consequence of stenosis is the development of ischemic damage to one or both kidneys, which causes hyperproduction of renin, which indirectly affects the increase in blood pressure.
The pathogenesis of the development of the endocrine etiological form of arterial hypertension is an increase in the level of hormonal substances that have a stimulating effect on increasing intravascular blood pressure, which occurs in Itsenko-Cushing syndrome, Conn syndrome and pheochromocytoma.Some cardiovascular diseases can act as a background pathology for the development of secondary arterial hypertension, for example, coarctation of the aorta.
Symptoms of arterial hypertension
Clinical manifestations in the initial phase of the development of arterial hypertension may be completely absent, and the diagnosis in this case is based only on the data of an objective and instrumental laboratory examination.
Complaints of patients suffering from arterial hypertension are rather non-specific, and because of this, at the beginning of essential hypertension, the diagnosis is significantly difficult.In most cases, during an episode of arterial hypertension, the patient suffers from a headache with a predominant localization in the frontal and occipital part, severe dizziness, especially when changing the position of the body in space, and pathological tinnitus.These manifestations are not pathognomonic, therefore it is not recommended to consider them as clinical criteria for arterial hypertension, since the above symptoms are occasionally observed in absolutely healthy people and have nothing to do with elevated blood pressure.Classic clinical manifestations in the form of respiratory disorders and signs of cardiac dysfunction are observed only in the advanced stage of arterial hypertension.
Some etiopathogenetic forms of arterial hypertension are accompanied by the development of specific clinical symptoms, and therefore an experienced specialist can make the correct diagnosis during the initial examination and careful collection of anamnesis.For example, in the renovascular type of arterial hypertension, there is always an acute onset of clinical manifestations, which consist of a sharp critical and constant increase in blood pressure, mainly due to the diastolic component.Renovascular arterial hypertension is not characterized by a crisis course, however, the well-being of patients with this pathology is extremely difficult.
Endocrine arterial hypertension, on the contrary, is characterized by a tendency to a paroxysmal course of the disease with the development of classic hypertensive crises.This pathology is characterized by the patient's clinical "paroxysmal triad", which consists of the development of a severe headache, profuse sweating and rapid heartbeat.Patients in this pathological condition are characterized by extreme psycho-emotional excitability.The development of a hypertensive crisis most often occurs at night, and the duration of clinical manifestations does not exceed one hour, after which patients notice severe weakness and a dull, widespread headache.
Degrees and stages of arterial hypertension
Determining the severity and intensity of clinical manifestations of arterial hypertension, as well as the stage of disease development, is a prerequisite for choosing an adequate treatment regimen.The division of arterial hypertension of primary and symptomatic origin is based on the level of increase in the systolic and diastolic components of blood pressure.
Patients with arterial hypertension of the 1st degree most often do not notice significant damage to their own health due to the fact that blood pressure values in this situation do not exceed 159/99 mm.capeArt.
Arterial hypertension of the 2nd degree is accompanied by pronounced clinical manifestations and organic changes in the target organs, and blood pressure indicators are in the range of 179/109 mm.capeArt.
Stage 3 of the disease is characterized by an extremely severe aggressive course and a tendency to develop complications due to brain and heart dysfunction.In the third degree, there is a critical increase in blood pressure over 180/110 mm.capeArt.
In addition to the classification of arterial hypertension according to severity, in practice cardiologists use a stage division of this pathology, the criterion of which is the presence of signs of damage to target organs.
In the initial stage of arterial hypertension of primary and secondary origin, the patient has absolutely no manifestations of organic damage to tissues and organs sensitive to increased blood pressure.
The second stage of the disease includes the development of detailed clinical symptoms, the intensity of which directly depends on the severity of damage to the internal organs.However, in most cases, this stage of arterial hypertension is determined on the basis of instrumental confirmation of organ damage in the form of hypertrophic cardiomyopathy of the left ventricle of the heart according to echocardioscopy and ECG, narrowing of retinal arterial vessels during fundus examination and the presence of changes in blood orifice parameters, increase in biochemical parameters of blood vessels and blood vessels.level.
The third stage of arterial hypertension is terminal, in which the patient develops irreversible changes in all organs sensitive to elevated blood pressure.In relation to the heart, a person who suffers from high blood pressure for a long time develops ischemic damage to the myocardium, which is manifested by the formation of infarct zones.Arterial hypertension negatively affects the structures of the brain in the form of provocation of transient ischemic attacks, hypertensive encephalopathy, and even the creation of foci of ischemic stroke.A long-term systemic increase in intravascular pressure has an extremely negative effect on the structure of the fundus vessels, resulting in bleeding in the retina and swelling of the optic nerve head.
The terminal stage of the development of arterial hypertension is characterized by significant suppression of renal function, which is reflected in creatinine levels that exceed 177 µmol/l.
Diagnosis of arterial hypertension
When conducting a clinical and instrumental-laboratory examination of a patient with arterial hypertension, the main goal should be not so much to determine the fact of elevated blood pressure, but to discover the cause of the development of secondary arterial hypertension, signs of damage to internal organs, as well as to assess the presence of risk factors for the development of cardiac complications.
During the first contact with the patient, the key to making the correct diagnosis and determining the tactics of further treatment is the careful collection of anamnestic data about the patient.An objective examination of a patient suffering from arterial hypertension in some cases makes it possible to determine the etiopathogenetic form of the disease, due to the detection of specific pathognomonic signs.Therefore, with the existing abdominal type of obesity in the patient, in combination with hypertrichosis, hirsutism and a persistent increase in the diastolic component of blood pressure, the endocrine nature of the disease (Itsenko-Cushing syndrome) should be assumed.In pheochromocytoma, accompanied by severe paroxysmal arterial hypertension, an increase in skin pigmentation is observed in the projection of the armpit.The main diagnostic clinical criterion for renovascular arterial hypertension is the auscultation of vascular noise in the projection of the peri-umbilical region.
The scope of laboratory methods for the investigation of arterial hypertension consists of the analysis of the patient's lipid profile, the determination of uric acid and creatinine as the main criteria for renal dysfunction, and the analysis of the patient's hormonal status.
In order to determine the stage of the disease, a necessary condition is the diagnosis of damage to the target organ, i.e. organs in which irreversible changes occur due to increased blood pressure.Thus, to examine the heart for dysfunction and organic damage, electrocardiographic imaging and ultrasound imaging are used, which are part of the standard screening examination of all patients suffering from arterial hypertension.In order to detect retinopathy, which mainly occurs in long-term severe arterial hypertension, it is necessary to examine the patient's fundus.As instrumental methods for studying the kidneys and brain, it is recommended to use radiation methods that are not included in the mandatory list of diagnostic measures, but greatly facilitate the early establishment of the correct diagnosis (computed tomography, magnetic resonance).
Treatment of arterial hypertension
The basic modern approach to the treatment of arterial hypertension is to achieve maximum elimination of the risk of developing cardiac complications and the mortality rate.In this sense, the primary task of the doctor is the complete elimination of reversible (modifiable) risk factors present in the patient, along with further medication relief of arterial hypertension and accompanying clinical manifestations.There is a certain standard, which consists in achieving the target blood pressure limit, the values of which should not exceed 140/90 mmHg.
In which cases should antihypertensive therapy be used for arterial hypertension?In their practice, cardiologists use a developed classification, which includes an assessment of the patient's "risk of developing cardiovascular complications".According to this classification, people with a high risk of cardiac complications combined with a critical increase in blood pressure are subject to combined treatment with lifestyle modification and medication correction.Patients who are classified as moderate and low-risk are subject to dynamic monitoring for at least three months, and only if there is no effect from the use of non-drug correction methods, drug antihypertensive therapy should be resorted to.
The principles of medical correction of arterial hypertension consist of a gradual lowering of blood pressure to target values by applying the minimum therapeutic dose of one or more antihypertensive drugs.In some situations, monotherapy with a low dose of an antihypertensive drug can have a long-term positive effect in terms of relieving arterial hypertension.Currently, the pharmaceutical market is filled with a wide range of antihypertensive drugs, but the most popular are combined groups of drugs that have a prolonged hypotensive effect (up to 24 hours).
As the drugs of choice for the first episode of arterial hypertension, priority should be given to diuretics that have a wide range of positive effects in the form of preventing the development of cardiovascular complications, reducing mortality, as well as preventing the progression of hypertrophic changes in the myocardium of the left ventricle of the heart.The pharmacological effect, accompanied by a slight decrease in blood pressure, is caused by a decrease in water and sodium reabsorption and a decrease in vascular resistance.
The choice of diuretic drug depends on the patient's existing concomitant diseases.Therefore, in the case of arterial hypertension combined with signs of heart and kidney failure, preference should be given to loop diuretics.Thiazide diuretics with long-term use can cause the development of hypokalemic syndrome, so it is better to use them in combination with aldosterone antagonists.
In a situation where the patient has signs of arterial hypertension in combination with tachyarrhythmia, angina attacks and symptoms of congestive chronic cardiovascular failure, it is recommended to use the group of B-blockers as first-line drugs.The mechanism of antihypertensive action of these drugs is to reduce cardiac output and inhibit renin production.It should be taken into account that non-adherence to the dose of the drug in this group can cause a pronounced decrease in heart rate and bronchoconstriction, which is an absolute indication to stop taking B-blockers.
It is recommended to prescribe antihypertensive drugs from the group of ACE inhibitors to patients suffering from arterial hypertension due to proteinuria.An absolute contraindication for the use of drugs from the group of ACE inhibitors is existing bilateral renal stenosis in the patient.Drugs from the group of angiotensin II receptor antagonists have a similar hypotensive effect, with the only difference being that they do not cause the development of cough and angioedema, which significantly expands the scope of their use.
Medicines from the group of calcium channel blockers have a pronounced hypotensive effect, which makes it possible to alleviate arterial hypertension by reducing the calcium content in the vascular wall.The category for prescribing drugs in this group consists mainly of elderly patients who, at the same time as arterial hypertension, show signs of ischemic damage to the myocardium, which are manifested in the onset of angina attacks.In cardiology practice, only long-acting forms of calcium channel blockers are used due to the fact that short-acting calcium antagonists significantly increase the risk of provoking an acute myocardial infarction.
In a situation where the patient's arterial hypertension is combined with a violation of the rhythm of cardiac activity, it is recommended to use calcium antagonists from the category of phenylalkylamines and benzothiazepine derivatives.An absolute contraindication for the use of this category of drugs is existing heart failure in the patient, accompanied by a decrease in the ejection fraction by less than 45%.
Separately, it is necessary to consider drugs to relieve a hypertensive crisis, in which there is a critical increase in intravascular pressure and an acute course of arterial hypertension.In this situation, preference should be given to drugs with a pronounced antihypertensive effect, because with a prolonged hypertensive crisis, the risk of death increases sharply.If the patient has signs of a complicated hypertensive crisis, parenteral administration of drugs that have a hypotensive effect is preferable.Most groups of antihypertensive drugs are available in parenteral form.As a rule, the hypotensive effect occurs no later than 5 minutes after the administration of the drug.
In the case of an uncomplicated hypertensive crisis, there is no need for parenteral forms of antihypertensive drugs, because in this pathological condition there is no critical increase in blood pressure.Oral administration of antihypertensive drugs in adequate doses allows you to reduce blood pressure within a few hours and maintain target levels in the future.Of course, currently there are many methods for alleviating hypertensive crisis with drugs, however, in order to avoid the development of complications, it is necessary to regularly apply the planned regimen of antihypertensive therapy.
In cases where the patient's arterial hypertension is secondary and occurs as a consequence of renal artery stenosis, the basic method of treatment is surgical correction of the stenosis and revascularization with angioplasty.Surgical interventions for renovascular arterial hypertension (bypass operation, endarterectomy) are used only if there are contraindications for transluminal angioplasty.If the patient has signs of an aggressive course of arterial hypertension caused by severe unilateral nephrosclerosis, the only treatment method is nephrectomy.
For endocrine secondary arterial hypertension, a combination of surgical treatment (radical excision of the tumor substrate) and medical antihypertensive therapy (spironolactone in a daily dose of 200 mg for primary aldosteronism, phentolamine in a dose of 25 mg every 4 hours for pheochromocytoma) is used.
Prevention of arterial hypertension
Adherence to preventive measures, the effect of which is aimed at preventing episodes of elevated intravascular blood pressure, as well as reducing the risk of complications of arterial hypertension, is indicated not only for patients who have been suffering from this pathology for a long time, but also for healthy people who may have signs of high blood pressure.
It is a scientifically proven fact that there is a direct correlation between an increase in blood pressure and an increase in a person's body weight, and therefore normalizing the weight of a person suffering from arterial hypertension is the main priority preventive measure.In addition, following the rules for correcting dietary behavior helps prevent the progression of atherosclerotic damage to blood vessels, which is one of the main causes of the development of arterial hypertension.
The latest research in the field of pharmacology has proven the beneficial effect of Omega-3-polyunsaturated fatty acids on restoring vascular tone, which can also be considered an effective method for preventing arterial hypertension.Given these findings, you should consume olive oil in sufficient quantities every day and severely limit your intake of animal fats.
Of course, if you want to get rid of the manifestations of arterial hypertension, you should give up bad habits such as smoking and drinking alcoholic beverages, because nicotine and alcohol particles, even in microdoses, can increase intravascular blood pressure.
People who have already had episodes of arterial hypertension, as a secondary prevention, should measure their blood pressure daily, keep a special diary about the effectiveness of the applied drug therapy, and if the condition worsens and new clinical manifestations appear, report it immediately to the attending physician.
Arterial hypertension - which doctor will help?If you have or suspect the development of arterial hypertension, immediately seek the advice of a doctor such as a cardiologist, endocrinologist and nephrologist.