Arterial hypertension is a pathological or physiological tendency 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 other pathologies present in the patient.
According to global statistics, the epidemiological situation in terms of the occurrence of arterial hypertension is unfavorable, because the percentage of this pathology in the structure of cardiology diseases reaches 30%.There is a clear correlation between the increased risk of developing the signs and consequences of arterial hypertension with the increasing age of the patient, and therefore the main category of increased risk consists of adults and the elderly.
Causes of arterial hypertension
The appearance of signs of high blood pressure in patients may occur against the background of an existing chronic disease, and then we are talking about the secondary version or symptoms of arterial hypertension.In cases where arterial hypertension is the main characteristic and even after a comprehensive examination of the patient it is not possible to determine the cause that provokes an increase in intravascular blood pressure, the term "hypertension" should be used, which is an independent form of nosology.
Primary arterial hypertension is observed in almost 90% of cases of pre-existing increased blood pressure, and the polyetiology of the development of this pathological condition is being considered.Therefore, there are non-modifiable risk factors for arterial hypertension, which cannot be avoided (gender, genetic determination and age), however, these provoking factors are not dominant in the development of severe arterial hypertension.To a greater extent, the development of signs of primary arterial hypertension is influenced by a person's lifestyle (unbalanced diet, bad habits, inactivity, psycho-emotional instability).Taken together, all the above 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 do not have any impact on patient management tactics and determine 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 factors that cause an increase in blood pressure, in this case one cannot expect a positive treatment result.
Therefore, 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.A very rare etiological factor affecting the renal arteries is systemic vasculitis.The consequence of stenosis is the development of ischemic damage to one or both kidneys, causing hyperproduction of renin, which has an indirect effect on increasing blood pressure.
The pathogenesis of the development of the endocrine form of the etiology of arterial hypertension is an increase in the level of hormonal substances that have a stimulating effect on the increase in intravascular blood pressure, which occurs in Itsenko-Cushing syndrome, Conn's 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 early stages of the development of arterial hypertension may be completely absent, and the diagnosis in this case is based only on objective and instrumental laboratory examination data.
Complaints made by patients suffering from arterial hypertension are quite non-specific, and therefore, at the onset of essential hypertension, diagnosis is very difficult.In most cases, during episodes of arterial hypertension, patients are disturbed by headaches with primary localization in the frontal and occipital regions, 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 observed periodically in completely healthy people and have nothing to do with increased blood pressure.Classic clinical manifestations in the form of respiratory disorders and signs of cardiac dysfunction are observed only in advanced stages of arterial hypertension.
Some etiopathogenetic forms of arterial hypertension are accompanied by the development of certain clinical symptoms, and therefore, an experienced specialist can establish the correct diagnosis during the initial examination and careful anamnesis collection.For example, with the type of renovascular arterial hypertension, there is always an acute onset of clinical manifestations, consisting of a critical and persistent 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 very difficult.
Endocrine arterial hypertension, on the other hand, is characterized by a tendency to paroxysmal course of the disease with the development of a classic hypertensive crisis.This pathology is characterized by the patient's clinical "paroxysmal triad", which consists of the development of severe headache, severe sweating and rapid heartbeat.Patients in this pathological condition are characterized by extreme psycho-emotional excitement.The development of a hypertensive crisis most often occurs at night, and the duration of clinical manifestations does not exceed an hour, after which the patient notices severe weakness and a dull and widespread headache.
Levels and stages of arterial hypertension
Determining the severity and intensity of the clinical manifestations of arterial hypertension, as well as the stage of disease progression, is a prerequisite for choosing an adequate treatment regimen.The division of arterial hypertension of both primary and symptomatic origin is based on the degree of increase in the systolic and diastolic components of blood pressure.
Patients with stage 1 arterial hypertension most often do not notice a significant deterioration in their own health due to the fact that the blood pressure figure in this condition does not exceed 159/99 mm.right.Art.
Stage 2 arterial hypertension is accompanied by clear clinical manifestations and organic changes in target organs, and blood pressure indicators are in the range of 179/109 mm.right.Art.
Stage 3 of the disease is characterized by a very severe aggressive course and a tendency to develop complications from brain and heart dysfunction.In the third stage, there is a critical increase in blood pressure above 180/110 mm.right.Art.
In addition to classifying arterial hypertension according to severity, in practice, cardiologists use this staged division of pathology, the criterion of which is the presence of signs of damage to the target organs.
In the early stages of arterial hypertension of both primary and secondary origin, patients do not have any manifestations of organic damage to tissues and organs that are sensitive to increased blood pressure.
The second stage of the disease involves the development of detailed clinical symptoms, the intensity of which directly depends on the severity of the damage to the internal organs.However, in most cases, this stage of arterial hypertension is established based on instrumental confirmation of organ damage in the form of left ventricular hypertrophic cardiomyopathy according to echocardioscopy and ECG, narrowing of retinal artery vessels during fundus examination and the presence of changes in biochemical blood test parameters, i.e. a moderate increase in creatinine levels.
The third stage of arterial hypertension is terminal, in which the patient experiences the development of irreversible changes in all organs that are sensitive to increased blood pressure.In relation to the heart, a person suffering from high blood pressure for a long time experiences ischemic damage to the myocardium, which manifests itself in the formation of an infarction zone.Arterial hypertension has a negative effect on the structure of the brain in the form of provocation of transient ischemic attacks, hypertensive encephalopathy, and also the formation of focal ischemic strokes.A long-term systemic increase in intravascular pressure has a very negative effect on the structure of the fundus canal, which results in the formation of hemorrhages in the retina and swelling of the optic nerve head.
The terminal stage of the development of arterial hypertension is characterized by a significant suppression of kidney function, which is reflected in the level of creatinine, which exceeds 177 µmol/l.
Diagnosis of arterial hypertension
When conducting a clinical and instrumental laboratory examination of patients with arterial hypertension, the main goal is not to determine the fact of increased blood pressure, but to find out the causes 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 initial contact with the patient, the key to establishing the correct diagnosis and determining further treatment tactics is the careful collection of the patient's anamnesis data.Objective examination of patients suffering from arterial hypertension, in some cases, allows us to determine the etiopathogenetic form of the disease, due to the detection of certain pathognomonic signs.Therefore, with the type of abdominal obesity present in the patient, combined with hypertrichosis, hirsutism and a constant increase in the diastolic component of blood pressure, one should consider the endocrine nature of the disease (Itsenko-Cushing syndrome).With pheochromocytoma, accompanied by severe paroxysmal arterial hypertension, increased skin pigmentation is observed in the axillary projection.The main diagnostic clinical criteria for renovascular arterial hypertension is considered to be the auscultation of a vascular murmur in the projection of the peri-umbilical region.
The scope of laboratory research methods for arterial hypertension consists of analyzing the patient's lipid profile, determining uric acid and creatinine as the main criteria for renal dysfunction, and analyzing the patient's hormonal status.
To determine the stage of the disease, a necessary condition is the diagnosis of damage to the target organ, that is, the organ in which irreversible changes develop due to increased blood pressure.Therefore, to check the heart for dysfunction and organic damage, electrocardiographic recording and ultrasound imaging are used, which are part of the standard screening examination for all patients with arterial hypertension.To detect retinopathy, which is observed mainly with long-term severe arterial hypertension, it is necessary to examine the patient's fundus.As an instrumental method for studying the kidneys and brain, it is advisable to use radiation imaging methods, which are not included in the mandatory list of diagnostic measures, but greatly facilitate the early establishment of the correct diagnosis (computed tomography, magnetic resonance imaging).
Treatment of arterial hypertension
The basic modern approach to the treatment of arterial hypertension is to achieve the maximum elimination of the risk of developing cardiac complications and mortality.In this regard, the main task of the attending physician is the complete elimination of reversible (modifiable) risk factors present in the patient, with the help of further medication of arterial hypertension and accompanying clinical manifestations.There are certain standards, which consist of reaching the target blood pressure limit, whose value should not exceed 140/90 mmHg.
In what case should antihypertensive therapy be used for arterial hypertension?Cardiologists in their practice use the developed classification, which involves the assessment of the patient's "risk for developing cardiovascular complications".According to this classification, people at high risk of developing cardiac complications in combination with a critical increase in blood pressure are subject to combined treatment using lifestyle modifications and drug correction.Patients classified as medium and low risk are subject to dynamic observation for at least three months, and only if there is no effect from the use of non-drug correction methods, drug antihypertensive treatment should be taken.
The principle of drug correction of arterial hypertension consists of a gradual reduction of blood pressure to the target value by using a minimum therapeutic dose of one or more antihypertensive drugs.In some cases, monotherapy with low doses of antihypertensive drugs may have a long-term positive effect in terms of relieving arterial hypertension.Currently, the pharmaceutical market is filled with various types of antihypertensive drugs, but the most popular is the combined group of drugs that have a prolonged hypotensive effect (up to 24 hours).
As the drug of choice for the first episode of arterial hypertension, priority should be given to diuretics that have various positive effects in the form of preventing the development of cardiovascular complications, reducing mortality, and also preventing the development of hypertrophic changes in the myocardium of the left ventricle of the heart.Pharmacological effect, accompanied by a moderate decrease in blood pressure, due to a decrease in the reabsorption of water and sodium and a decrease in vascular resistance.
The choice of diuretic depends on the patient's existing concomitant diseases.Therefore, in the case of arterial hypertension combined with signs of heart and kidney failure, priority should be given to loop diuretics.Thiazide diuretics with long-term use can trigger the development of hypokalemic syndrome, and therefore it is better to use them in combination with aldosterone antagonists.
In situations where the patient has signs of arterial hypertension combined with tachyarrhythmia, angina attacks and symptoms of chronic congestive cardiovascular failure, it is advisable to use a group of B blockers as a first-line drug.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-compliance with the dosage of the drug in this group can provoke a significant decrease in heart rate and bronchoconstriction, which is an absolute indication for the discontinuation of B-blockers.
For patients with arterial hypertension due to proteinuria, it is advisable to prescribe antihypertensive drugs from the ACE inhibitor group.An absolute contraindication to the use of drugs from the ACE inhibitor group is the patient's existing bilateral renal stenosis.Drugs from the group of angiotensin II receptor antagonists have the same hypotensive effect, with the only difference being that they do not trigger the development of cough and angioedema, which significantly expands the scope of their use.
Drugs from the group of calcium channel blockers have a pronounced hypotensive effect, which makes it possible to relieve 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 myocardial damage, which is manifested in the development 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 triggering an acute myocardial infarction.
In situations where arterial hypertension in patients is combined with a violation of the rhythm of cardiac activity, it is advisable to use calcium antagonists from the category of phenylalkylamines and benzothiazepine derivatives.An absolute contraindication to the use of this category of drugs is the patient's existing heart failure, accompanied by a decrease in ejection fraction of less than 45%.
Separately, we should consider the release of hypertensive crisis drugs, where there is a critical increase in intravascular pressure and an acute course of arterial hypertension.In this situation, priority should be given to drugs with a clear antihypertensive effect, because with a prolonged hypertensive crisis, the risk of death increases dramatically.If the patient has signs of a complex hypertensive crisis, the parenteral route of administration of drugs that have a hypotensive effect is better.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, it is not necessary to use parenteral forms of antihypertensive drugs, because in this pathological condition there is no critical increase in blood pressure.Oral administration of antihypertensive drugs in sufficient doses allows you to reduce blood pressure in a few hours and maintain the target level in the future.Of course, currently there are many methods of releasing hypertensive crisis drugs, however, to avoid the development of complications, a planned antihypertensive therapy regimen should be used periodically.
In cases where arterial hypertension in the patient is secondary and develops due to renal artery stenosis, the basic treatment method is surgical correction of stenosis and revascularization using angioplasty.Surgical procedures for renovascular arterial hypertension (bypass surgery, endarterectomy) are used only if there are contraindications to the use of 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 removal of the tumor substrate) and drug antihypertensive therapy is used (Spironolactone at a daily dose of 200 mg for primary aldosteronism, Phentolamine at a dose of 25 mg every 4 hours for pheochromocytoma).
Prevention of arterial hypertension
Compliance with preventive measures, the effect of which is aimed at preventing episodes of increased intravascular blood pressure, as well as reducing the risk of complications of arterial hypertension, is indicated not only for patients who have long suffered from this pathology, but also for healthy individuals who may experience 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 body weight of a person suffering from arterial hypertension is the main priority preventive measure.In addition, compliance with the rules to correct eating behavior helps prevent the development of atherosclerotic vascular damage, which is one of the main causes of the development of arterial hypertension.
Recent studies in the field of pharmacology have proven the beneficial effect of Omega-3 polyunsaturated fatty acids on restoring vascular tone, which can also be considered an effective method of preventing arterial hypertension.In light of these findings, you should consume olive oil in sufficient quantities every day and sharply limit your animal fat intake.
Of course, if you want to get rid of the manifestations of arterial hypertension, you should abandon bad habits such as smoking and drinking alcoholic beverages, because nicotine particles and alcohol, even in micro doses, can increase intravascular blood pressure.
People who have experienced an episode of arterial hypertension, as a secondary preventive measure, should measure blood pressure daily, keep a special diary that describes the effectiveness of drug therapy used, and if the condition worsens and new clinical manifestations appear, immediately report this to the attending physician.
Arterial hypertension - which doctor will help?If you have or suspect the development of arterial hypertension, you should immediately seek advice from doctors such as cardiologists, endocrinologists and nephrologists.