Arterial hypertension is a pathological or physiological predisposition to a sharp or gradual increase in both the systolic and diastolic components of intravascular blood pressure, occurring as an independent nosological unit or as a manifestation of another pathology present in the patient.
According to world statistics, the epidemiological situation regarding the frequency of arterial hypertension is unfavorable, since the percentage of this pathology in the structure of cardiac diseases reaches 30%.There is a clear relationship between the increased risk of developing signs and consequences of arterial hypertension with increasing age of the patient, therefore the main category of increased risk consists of the elderly and the elderly.
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 has a primary character and even after a comprehensive examination of the patient it is not possible to determine the cause provoking 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 that cannot be avoided (gender, genetic determination and age), but 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, lack of activity, psycho-emotional instability).Taken together, all the above-mentioned provoking factors sooner or later create favorable conditions for the pathogenetic development of arterial hypertension.
Currently, many pathogenetic theories for the development of essential arterial hypertension are considered, although these hypotheses do not have any influence on the patient's treatment 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 results of treatment 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 etiological factor affecting the renal arteries is systemic vasculitis.The consequence of the stenosis is the development of ischemic damage to one or both kidneys, which provokes hyperproduction of renin, which has an indirect effect on 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 is manifested in Itsenko-Cushing syndrome, Kohn 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 data from objective and instrumental laboratory research.
Complaints of patients with arterial hypertension are quite non-specific, therefore, at the beginning of essential hypertension, the diagnosis is significantly difficult.In most cases, during an episode of arterial hypertension, the patient is bothered by headaches with a predominant 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 absolutely healthy people and have nothing to do with increased blood pressure.The classic clinical manifestations in the form of respiratory disorders and signs of cardiac dysfunction are observed only in an advanced stage of arterial hypertension.
Some etiopathogenetic forms of arterial hypertension are accompanied by the development of specific clinical symptoms, which is why an experienced specialist can establish the correct diagnosis during an initial examination and careful history taking.For example, in the renovascular type of arterial hypertension, there is always an acute onset of clinical manifestations, consisting 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, but the well-being of the patient with this pathology is extremely difficult.
Endocrine arterial hypertension, on the contrary, is characterized by a tendency towards 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 an accelerated heart rate.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 more than an 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 development of the disease, is a prerequisite for choosing an appropriate treatment regimen.The separation of arterial hypertension of both 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 first stage 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.rt.Art.
Arterial hypertension in stage 2 is accompanied by pronounced clinical manifestations and organic changes in target organs, and blood pressure indicators are within 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, a critical increase in blood pressure above 180/110 mm is observed.rt.Art.
In addition to classifying arterial hypertension by severity, in practice, cardiologists use a staged 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 both 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 the damage to the 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 the parameters of a biochemical blood test, namely a moderate increase in plasma creatinine 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 who suffers from high blood pressure for a long time develops ischemic damage to the myocardium, which is expressed in the formation of infarct zones.Arterial hypertension has a negative effect on brain structures in the form of provoking transient ischemic attacks, hypertensive encephalopathy and even formation of foci of ischemic stroke.The long-term systemic increase in intravascular pressure has an extremely negative effect on the structure of the vessels of the fundus, which leads to the formation of hemorrhages in the retina and swelling of the optic nerve head.
The terminal stage of 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 clinical and instrumental-laboratory examination of patients with arterial hypertension, the main goal should be not so much to establish the fact of increased blood pressure, but rather to find 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.
At 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.In pheochromocytoma, accompanied by severe paroxysmal arterial hypertension, an increase in skin pigmentation is observed in the projection of the armpits.The main diagnostic clinical criterion for renovascular arterial hypertension is considered to be the auscultation of vascular noise in the projection of the umbilical region.
The range of laboratory methods for the study of arterial hypertension consists of an analysis of the patient's lipid profile, determination of uric acid and creatinine as the main criteria for renal dysfunction, and 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 organs, that is, organs in which irreversible changes develop due to increased 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 of all patients with arterial hypertension.In order to detect retinopathy, which is mainly observed in long-term severe arterial hypertension, it is necessary to examine the patient's fundus.As instrumental methods for examining 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 a correct diagnosis (computed tomography, nuclear magnetic resonance).
Treatment of arterial hypertension
The main modern approach in the treatment of arterial hypertension is to achieve 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 the reversible (modifiable) risk factors present in the patient, with subsequent drug relief of arterial hypertension and its 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 what cases should antihypertensive therapy be used for arterial hypertension?Cardiologists in their practice use the developed classification, which includes an assessment of the patient's "risk of developing cardiovascular complications".According to this classification, individuals at high risk of cardiac complications in combination with a critical increase in blood pressure are subject to combined treatment with lifestyle changes and drug correction.Patients classified as moderate and low risk are subject to dynamic monitoring for at least three months, and only if there is no effect of using non-drug methods of correction, drug antihypertensive treatment should be resorted to.
The principles of drug correction of arterial hypertension consist in a gradual reduction of blood pressure to the target values by using a 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 full of a wide range of antihypertensive drugs, but the most popular are the combined groups of drugs that have a long-lasting hypotensive effect (up to 24 hours).
As drugs of choice in the first episode of arterial hypertension, preference should be given to diuretics, which 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 due to a decrease in the reabsorption of water and sodium and a decrease in vascular resistance.
The choice of diuretic drug depends on the patient's existing comorbidities.Thus, 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 provoke the development of a 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 tachyarrhythmia, angina attacks and symptoms of congestive chronic cardiovascular failure, it is recommended to use group B-blockers as first-line drugs.The mechanism of antihypertensive action of these drugs is a reduction in cardiac output and inhibition of renin production.It should be borne in mind that non-compliance with the dosage of the drug from this group can cause a pronounced decrease in heart rate and bronchoconstriction, which is an absolute indication for stopping the B-blocker.
In patients suffering from arterial hypertension due to proteinuria, it is recommended 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 patient's existing bilateral renal stenosis.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, which allows the relief of 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 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 an acute myocardial infarction.
In a situation where arterial hypertension in a patient is combined with a disturbance of the rhythm of cardiac activity, it is recommended 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 the ejection fraction below 45%.
Separately, we must consider the medicinal relief of 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 hypertensive crisis, the risk of death increases sharply.If the patient has signs of a complicated hypertensive crisis, parenteral administration of drugs with 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 administration of the drug.
In the case of an uncomplicated hypertensive crisis, it is not necessary 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 an adequate dose allows you to reduce blood pressure within a few hours and maintain target levels in the future.Of course, currently there are many methods of medicinal relief of hypertensive crisis, but in order to avoid the development of complications, a planned regimen of antihypertensive therapy should be regularly applied.
In cases where arterial hypertension in the patient is secondary and develops as a result of stenosis of the renal arteries, the main method of treatment is surgical correction of the stenosis and revascularization using angioplasty.Surgical procedures for renovascular arterial hypertension (bypass, 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.
In endocrine secondary arterial hypertension, a combination of surgical treatment (radical excision of the tumor substrate) and drug 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
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 suffer from this pathology for a long time, but also for healthy individuals who may experience signs of high blood pressure.
A scientifically proven fact is the direct relationship between an increase in blood pressure and an increase in a person's body weight, which is why normalizing the weight of a person suffering from arterial hypertension is the main priority preventive measure.In addition, compliance with the rules for correcting dietary behavior helps to prevent the progression of atherosclerotic vascular damage, which is one of the main reasons for the development of arterial hypertension.
Recent studies in the field of pharmacology have proven the beneficial effect of Omega-3 polyunsaturated fatty acids in restoring vascular tone, which can also be considered an effective method of preventing arterial hypertension.Given these findings, you should consume olive oil in sufficient quantities daily and sharply limit your intake of animal fats.
Of course, if you want to get rid of the manifestations of arterial hypertension, you must 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 blood pressure daily, keep a special diary reflecting the effectiveness of the 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 a cardiologist, endocrinologist and nephrologist.