Arterial hypertension is a pathological or physiological predisposition to a sharp or gradual increase in 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 in terms of the incidence of arterial hypertension is unfavorable, since the percentage of this pathology in the structure of cardiological diseases reaches 30%.There is a clear correlation between the increased risk of the appearance of signs and consequences of arterial hypertension with increasing age of the patient, and therefore the main category of increased risk consists of mature and elderly persons.
Causes of arterial hypertension
The appearance of signs of high blood pressure in a patient can occur against the background of existing chronic diseases, and then we are talking about a 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 provokes 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 blood pressure increase, and the polyetiology of the development of this pathological condition is currently being examined.So, there are non-modifiable risk factors for arterial hypertension, which cannot be avoided (gender, genetic determination and age), however, these provocative 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 provocative factors sooner or later create favorable conditions for the pathogenic development of arterial hypertension.
Currently, many pathogenic theories of the development of essential arterial hypertension are being considered, although these hypotheses do not have any influence on patient management tactics and determining the scope of therapeutic measures.To a greater extent, the etiopathogenesis of the development of secondary arterial hypertension should be taken into account, since without eliminating the etiological factor that provokes 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 pathogenic link is renal artery stenosis, which occurs due to atherosclerotic lesions or fibromuscular dysplasia.An extremely 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, provoking 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 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 initial stage 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 made by patients suffering from arterial hypertension are quite non-specific, and therefore, at the beginning of essential hypertension, the diagnosis is obviously difficult.In most cases, during an episode of arterial hypertension, the patient is disturbed by a headache with a predominant localization in the frontal and occipital region, severe dizziness especially when changing the position of the body in space and pathological tinnitus.These manifestations are not pathognomonic, therefore it is not advisable to consider them clinical criteria for arterial hypertension, since the above symptoms are periodically observed in absolutely healthy people and are not related to increased blood pressure.Classic clinical manifestations in the form of breathing disorders and signs of heart 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 an initial examination and careful collection of anamnesis.For example, with the renovascular type of arterial hypertension, there is always an acute onset of clinical manifestations, consisting of a sharp critical and continuous 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 the patient 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 clinical "paroxysmal triad" of the patient, 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 occurs more often at night, and the duration of clinical manifestations does not exceed an hour, after which patients notice severe weakness and a dull and 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 stage 1 most often do not notice a significant damage to their health due to the fact that the blood pressure figures in this situation do not exceed 159/99 mm.rt.Art.
Stage 2 arterial hypertension is associated with pronounced clinical manifestations and organic changes in the target organs, and blood pressure indicators are within the range of 179/109 mm.rt.Art.
Stage 3 of the disease is characterized by an extremely severe aggressive course and a tendency to develop complications from brain and heart dysfunction.In the third degree, there is a critical increase in blood pressure that exceeds 180/110 mm.rt.Art.
In addition to the classification of arterial hypertension according to severity, in practice, cardiologists use a graded division of this pathology, the criterion of which is the presence of signs of damage to the target organs.
In the initial stage of arterial hypertension of primary and secondary origin, the patient does not have any manifestations of organic damage to tissues and organs 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 damage to internal organs.However, in most cases, this stage of arterial hypertension is established 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 parameters, an increase in the parameters of a biological chemical test.levels.
The third stage of arterial hypertension is terminal, in which the patient experiences the development of irreversible changes in all organs sensitive to increased blood pressure.Regarding the heart, a person suffering from high blood pressure for a long time develops ischemic damage to the myocardium, which is manifested in the formation of areas of infarction.Arterial hypertension has a negative effect on brain structures in the form of provoking transient ischemic attacks, hypertensive encephalopathy, and even the formation 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, which results in the formation of hemorrhages in the retina and swelling of the optic nerve head.
The final stage of the development of arterial hypertension is characterized by a significant suppression of kidney function, which is reflected in creatinine levels that exceed 177 μmol/l.
Diagnosis of arterial hypertension
When performing a clinical and instrumental-laboratory examination of patients with arterial hypertension, the main goal should be not so much to prove the fact of increased 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 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 anamnestic data.Objective examination of a patient suffering from arterial hypertension, in some cases, allows us to determine the etiopathogenetic form of the disease, due to the detection of specific pathognomonic signs.Thus, with the existing abdominal type of obesity in a patient, combined with hypertrichosis, hirsutism and a constant increase in the diastolic component of blood pressure, the endocrine nature of the disease (Itsenko-Cushing syndrome) should be assumed.With pheochromocytoma, accompanied by severe paroxysmal arterial hypertension, an increase in skin pigmentation is observed in the projection of the armpits.The main clinical diagnostic criterion for renovascular arterial hypertension is considered to be the auscultation of vascular noise in the projection of the peri-umbilical region.
The purpose of laboratory research methods for arterial hypertension consists in analyzing the patient's lipid profile, determining uric acid and creatinine as the main criteria for kidney dysfunction and analyzing 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. the organs in which irreversible changes develop due to the increase in blood pressure.Thus, to examine the heart for dysfunction and organic damage, electrocardiographic recording and ultrasound imaging are used, which are part of the standard screening examination of all patients suffering from arterial hypertension.To detect retinopathy, which is mainly observed with long-term severe arterial hypertension, it is necessary to examine the bottom of the patient.As an instrumental method for the study of 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 an accurate diagnosis (computed tomography, magnetic resonance).
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 the mortality rate.In this regard, the primary task of the attending physician is the complete elimination of reversible (modifiable) risk factors present in the patient, with further drug relief of arterial hypertension and associated clinical manifestations.There is a certain standard, which consists in reaching 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?Cardiologists in their practice use the developed classification, which includes the assessment of the patient's "risk of developing cardiovascular complications".According to this classification, people at high risk of cardiac complications in combination with a critical increase in blood pressure undergo combined treatment using lifestyle modification and medication correction.Patients classified as moderate and low risk undergo dynamic observation for at least three months, and only if there is no effect from the use of non-drug correction methods, antihypertensive drug treatment should be used.
The principles of drug correction of arterial hypertension consist in a gradual reduction of blood pressure to target values using a minimal 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 the combined groups of drugs that have a prolonged hypotensive effect (up to 24 hours).
As the drugs of choice for a 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 and also 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 existing comorbidities of the patient.Thus, in case of arterial hypertension combined with signs of heart and kidney failure, preference should be given to loop diuretic drugs.Thiazide diuretics with long-term use can provoke the development of hypokalemic syndrome, and therefore it is better to use them in combination with aldosterone antagonists.
In a situation where the patient has signs of arterial hypertension combined with tachyarrhythmias, angina attacks and symptoms of chronic congestive cardiovascular insufficiency, it is advisable to use a B-blocker group as first-line drugs.The mechanism of antihypertensive action of these drugs is to reduce cardiac output and inhibit renin production.It should be borne in mind that non-compliance with the dose of the drug in this group can provoke a marked decrease in heart rate and bronchoconstriction, which is an absolute indication for the discontinuation of the B-blocker.
For patients suffering from arterial hypertension due to proteinuria, it is advisable to prescribe antihypertensive drugs from the group of ACE inhibitors.An absolute contraindication to the use of drugs from the group of ACE inhibitors is the existing bilateral renal stenosis of the patient.Drugs from the group of angiotensin II receptor antagonists have a similar hypotensive effect, with the only difference that they do not provoke 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, making it possible to relieve arterial hypertension by reducing the calcium content in the vascular walls.The category for the prescription of drugs in this group consists mainly of elderly patients, who simultaneously with arterial hypertension show signs of ischemic damage to the myocardium, 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 provoking acute myocardial infarction.
In a situation where arterial hypertension in a patient is combined with a violation of the rhythm of cardiac activity, it is advisable to use calcium antagonists of 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 the ejection fraction of less than 45%.
Separately, we should consider drug relief for 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, since with a prolonged course of a hypertensive crisis, the risk of death increases significantly.If the patient has signs of a complicated hypertensive crisis, the parenteral route of administration of drugs that have a hypotensive effect is preferred.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 to use parenteral forms of antihypertensive drugs, since in this pathological condition there is no critical increase in blood pressure.Oral administration of antihypertensive drugs in the right dose allows you to lower blood pressure within a few hours and maintain target levels in the future.Of course, currently there are many methods for the relief of hypertensive crisis drugs, however, to avoid the development of complications, a planned regimen of antihypertensive therapy should be applied regularly.
In cases where arterial hypertension in a patient is secondary and develops as a result of stenosis of the renal arteries, the basic method of treatment is surgical correction of the stenosis and revascularization by means of 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 method of treatment is nephrectomy.
For secondary endocrine arterial hypertension, a combination of surgical treatment (radical removal of the tumor substrate) and antihypertensive drug therapy is used (Spironolactone in a daily dose of 200 mg for primary aldosteronism, Phentolamine in 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 suffering from this pathology for a long time, but also for healthy individuals who may have signs of high blood pressure.
A scientifically proven fact is a direct relationship between the increase in blood pressure numbers and the increase in a person's body weight, and therefore, normalizing the weight of a person suffering from arterial hypertension is the main preventive measure with priority.In addition, observing the rules for correcting eating behavior helps prevent the progression 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 effects of Omega-3 polyunsaturated fatty acids in 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 significantly 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, since nicotine and alcohol particles, even in microdoses, can increase intravascular blood pressure.
People who have already had episodes of arterial hypertension, as a secondary preventive measure, should measure their blood pressure every day, keep a special diary that reflects the effectiveness of drug therapy, and if the condition worsens and new clinical manifestations appear, immediately report it 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 cardiologist, endocrinologist and nephrologist.