Arterial hypertension is a pathological or physiological tendency to an acute or gradual increase in both systolic and diastolic components of intravascular blood pressure, which occurs as an independent nosological entity or as a manifestation of another pathology present in the patient.
According to global statistics, as the percentage of this pathology reaches 30% in the structure of cardiac diseases, the epidemiological situation in terms of cases of arterial hypertension is unfavorable.As the age of the patient increases, there is a clear relationship between the risk of developing symptoms and consequences of arterial hypertension, and therefore the main category of increased risk consists of adults and elderly people.
Causes of arterial hypertension
The appearance of symptoms of high 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 primary and even after a comprehensive examination of the patient, it is not possible to determine the cause of increased intravascular pressure, the independent nosological form of the term "hypertension" should be used.
Primary arterial hypertension is observed in almost 90% of current cases of increased blood pressure, and the polyetiology of the development of this pathological condition is currently being considered.Thus, there are non-modifiable risk factors for arterial hypertension, which cannot be avoided (gender, genetic predisposition and age), but these inciting factors do not dominate the development of severe arterial hypertension.The development of the main arterial hypertension symptoms is mostly influenced by a person's lifestyle (unbalanced diet, bad habits, inactivity, psycho-emotional instability).Taken together, all of the above-mentioned provoking factors create favorable conditions for the pathogenetic development of arterial hypertension.
Currently, many pathogenetic theories of the development of primary arterial hypertension are considered, although these hypotheses have no influence on patient management tactics and determination of the extent of therapeutic measures.The etiopathogenesis of the development of secondary arterial hypertension should be taken into account, because it is not necessary to expect positive treatment results in this case without eliminating the etiological factor that causes the increase in blood pressure.
Thus, the main pathogenetic link in the renovascular variant of symptomatic arterial hypertension 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 result of stenosis is the development of ischemic damage to one or both kidneys, which provokes the 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 pressure, which occurs 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
At the initial stage of the development of arterial hypertension, clinical manifestations may be completely absent, and in this case, the diagnosis is based only on objective and instrumental laboratory examination data.
Complaints of patients suffering from arterial hypertension are quite non-specific, and therefore the diagnosis at the beginning of the main hypertension becomes much more 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 and pathological tinnitus, especially when changing the position of the body in space.These manifestations are not pathognomonic, so it is not appropriate to consider them as clinical criteria for arterial hypertension, since the above symptoms are occasionally observed in completely healthy people and have nothing to do with an increase in blood pressure.Classical 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 determine the correct diagnosis during the 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 permanent increase in blood pressure, mainly due to the diastolic component.Renovascular arterial hypertension is not characterized by a crisis course, but the patient's well-being with this pathology is quite difficult.
Endocrine arterial hypertension, on the other hand, 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" consisting of severe headache, severe sweating and rapid heartbeat.Patients with this pathological condition are characterized by excessive 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 patients feel 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 adequate treatment regimen.The division 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 the 1st stage of arterial hypertension do not feel a significant disturbance in their health, since the blood pressure readings in this case do not exceed 159/99 mm.rt.Art.
Stage 2 arterial hypertension is accompanied by obvious clinical manifestations and organic changes in target organs, and blood pressure readings are in the range of 179/109 mm.rt.Art.
The 3rd stage of the disease is characterized by an extremely severe aggressive course and a tendency to develop complications arising from brain and heart dysfunction.In the third degree, there is a critical increase in blood pressure more than 180/110 mm.rt.Art.
In addition to classifying arterial hypertension according to severity, cardiologists in practice use a stage division of this pathology, the criteria of which are 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 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 changes in blood test parameters.levels.
The third stage of arterial hypertension is terminal, when the patient experiences the development of irreversible changes in all organs sensitive to increased blood pressure.In relation to the heart, a person suffering from high blood pressure for a long time develops ischemic damage to the myocardium, which manifests itself in the formation of heart attack zones.Arterial hypertension has a negative effect on brain structures in the form of provoking transient ischemic attacks, hypertensive encephalopathy and even the formation of ischemic stroke foci.A long-term systemic increase in intraocular pressure has an extremely negative effect on the structure of the retinal vessels, which results in the formation of retinal hemorrhages 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 creatinine level and exceeds 177 µmol/l.
Diagnosis of arterial hypertension
When conducting a clinical and instrumental-laboratory examination of patients with arterial hypertension, the main goal should not be to determine the fact of an increase in arterial pressure, but to detect the cause of the development of secondary arterial hypertension, to detect signs of damage to internal organs, as well as to assess the presence of risk factors for the development of heart complications.
Careful collection of patient's anamnestic data is the key to making the correct diagnosis and determining subsequent treatment tactics during the initial contact with the patient.Objective examination of a patient suffering from arterial hypertension, in some cases, due to the detection of specific pathognomonic signs, allows to determine the etiopathogenetic form of the disease.Thus, it is necessary to accept the endocrine nature of the disease (Itsenko-Cushing syndrome) with the type of abdominal obesity present in a patient with hypertrichosis, hirsutism and a continuous increase in the diastolic component of blood pressure.With pheochromocytoma accompanied by severe paroxysmal arterial hypertension, there is an increase in skin pigmentation in the projection of the armpits.The main diagnostic clinical criterion of renovascular arterial hypertension is the auscultation of vascular murmur in the projection of the umbilical cord.
The scope of laboratory research methods for arterial hypertension includes 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.
A necessary condition for determining the stage of the disease is the diagnosis of target organ damage, i.e. the organs where irreversible changes have developed due to increased arterial pressure.Thus, electrocardiographic recording and ultrasound imaging, which are part of the standard screening examination of all patients suffering from arterial hypertension, are used to check for cardiac dysfunction and organic damage.In order to detect retinopathy, which is mainly observed with 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 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 main modern approach to the treatment of arterial hypertension is to achieve the maximum elimination of the risk of developing cardiac complications and mortality rates.In this regard, the main task of the attending physician is to completely eliminate the reversible (modifiable) risk factors present in the patient with further drug treatment of arterial hypertension and accompanying clinical manifestations.There is a certain standard of reaching the target blood pressure limit, whose values do not exceed 140/90 mmHg.
In what cases should antihypertensive therapy be applied during arterial hypertension?In their practice, cardiologists use a developed classification that involves assessing the patient's "risk of developing cardiovascular complications."According to this classification, people with a high risk of cardiac complications with a critical increase in blood pressure are subjected to combined treatment using lifestyle changes 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 applied.
The principles of drug correction of arterial hypertension consist in the gradual lowering of blood pressure to target values by using the minimum therapeutic dose of one or more antihypertensive drugs.In some cases, monotherapy with a low dose of an antihypertensive drug can have a long-term positive effect in terms of eliminating arterial hypertension.Currently, the pharmaceutical market is full of a wide range of antihypertensive drugs, but the most popular are combination groups of drugs with a long-term hypotensive effect (up to 24 hours).
As the drugs of choice for the first episode of arterial hypertension, preference should be given to diuretics with a wide spectrum of positive effects in order to prevent the development of cardiovascular complications, reduce mortality, and also prevent the development of hypertrophic changes in the myocardium of the left ventricle of the heart.The pharmacological effect, which is accompanied by a moderate decrease in blood pressure, is due to a decrease in water and sodium reabsorption and a decrease in vascular resistance.
The choice of diuretic drugs depends on the patient's existing concomitant diseases.Thus, in the case of arterial hypertension combined with symptoms of heart and kidney failure, loop diuretic drugs should be preferred.With long-term use, thiazide diuretics can lead to the development of hypokalemic syndrome, and therefore it is better to use them together with aldosterone antagonists.
It is recommended to use group B-blockers as first-line drugs in a situation where the patient has symptoms of arterial hypertension with symptoms of tachyarrhythmia, angina attacks and congestive chronic cardiovascular failure.The mechanism of antihypertensive action of these drugs is to reduce cardiac output and inhibit renin production.It should be noted that non-compliance with the dosage of the drug in this group can lead to a sharp decrease in heart rate and bronchoconstriction, which is an absolute indication for stopping the B-blocker.
Antihypertensive drugs from the ACE inhibitor group are recommended for patients suffering from arterial hypertension due to proteinuria.An absolute contraindication for 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 a similar hypotensive effect, the only difference is that they do not cause cough and angioedema, which significantly expands their scope of use.
Drugs from the group of calcium channel blockers have an obvious hypotensive effect, which allows to eliminate arterial hypertension by reducing the amount of calcium in the vascular wall.The category of prescribing drugs in this group mainly consists of elderly patients who show signs of ischemic myocardial damage, manifested in the development of angina attacks simultaneously with arterial hypertension.In cardiology practice, only long-acting forms of calcium channel blockers are used because short-acting calcium antagonists significantly increase the risk of acute myocardial infarction.
In a situation where arterial hypertension in a patient is combined with heart rhythm disturbances, it is recommended to use calcium antagonists of the category of phenylalkylamines and benzothiazepine derivatives.An absolute contraindication to the use of drugs of this category is the existing heart failure accompanied by a decrease in the patient's ejection fraction of less than 45%.
Separately, we should consider the drug treatment of hypertensive crisis, which is a critical increase in intravascular pressure and an acute course of arterial hypertension.In this case, preference should be given to drugs with a clear antihypertensive effect, because the risk of death increases sharply with a prolonged hypertensive crisis.If the patient has symptoms of a complex hypertensive crisis, parenteral administration of hypotensive drugs 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 taking the drug.
In the case of an uncomplicated hypertensive crisis, there is no need to use parenteral forms of antihypertensive drugs, since there is no critical increase in blood pressure in this pathological condition.Adequate oral administration of antihypertensive drugs can reduce blood pressure within a few hours and maintain target levels in the future.Of course, currently there are many ways to eliminate hypertensive crisis with drugs, but to prevent the development of complications, a planned antihypertensive therapy regimen should be applied regularly.
In cases where arterial hypertension in the patient is secondary and develops as a result of stenosis of renal arteries, the main treatment method is surgical correction of stenosis and revascularization using angioplasty.Surgical procedures for renovascular arterial hypertension (bypass operation, endarterectomy) are used only when there are contraindications to the use of transluminal angioplasty.If the patient has symptoms 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 drug antihypertensive therapy is used (spironolactone at a dose of 200 mg daily for primary aldosteronism, Phentolamine at a dose of 25 mg every 4 hours for pheochromocytoma).
Prevention of arterial hypertension
Adherence to preventive measures 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 people who may experience symptoms 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, and therefore normalizing the weight of a person suffering from arterial hypertension is the main priority preventive measure.In addition, following the rules of correcting eating behavior helps to 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 the restoration of vascular tone, which can be considered an effective method for the prevention of arterial hypertension.Considering these findings, you should consume a sufficient amount of olive oil daily and drastically 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 pressure.
People who have already had episodes of arterial hypertension, as secondary preventive measures, should measure blood pressure every day, keep a special diary reflecting the effectiveness of the drug treatment used, and if the condition worsens and new clinical manifestations appear, they should immediately inform the attending physician.
Arterial hypertension - which doctor will help?If you suspect or suspect the development of arterial hypertension, you should immediately seek advice from doctors such as cardiologists, endocrinologists and nephrologists.