Arterial hypertension is a pathological or physiological tendency to a sharp or gradual increase in the systolic and diastolic components of intravascular blood pressure, which appears as an independent nosological entity or as a manifestation of other 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 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 the patient, therefore the main category of increased risk is mature and elderly people.
Causes of arterial hypertension
The appearance of signs of high blood pressure can occur against the background of chronic diseases in the patient, and then we talk about the secondary or symptomatic version of arterial high blood pressure.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 of the increase in intravascular blood pressure, the term "hypertension" should be used, which is an independent nosological form.
In almost 90% of cases of increased blood pressure, primary arterial hypertension is observed, and the polyetiology of the development of this pathological condition is currently being investigated.There are non-modifiable risk factors for the development of arterial hypertension that cannot be avoided (gender, genetics and age), however, these provoking factors are not dominant in the development of severe arterial hypertension.The development of signs of primary arterial hypertension is influenced to a greater extent by a person's lifestyle (unbalanced diet, bad habits, inactivity, psycho-emotional instability).Together, the above provocative factors sooner or later create favorable conditions for the pathogenetic development of arterial hypertension.
Currently, there are several pathogenetic theories of the development of essential arterial hypertension, although these hypotheses have no effect on the tactics of patient treatment and the definition of the range of therapeutic measures.The etiopathogenesis of the development of secondary arterial hypertension should be taken into account to a greater extent, since in this case no positive treatment results can be expected without the elimination of the etiological factor that causes the blood pressure to rise.
Thus, in the renovascular version of symptomatic arterial hypertension, the main pathogenetic link is the narrowing of the renal artery, which occurs due to atherosclerotic lesions or fibromuscular dysplasia.Systemic vasculitis is an extremely rare etiological factor affecting the renal arteries.The consequence of the stenosis is ischemic damage to one or both kidneys, which triggers an overproduction of renin, which indirectly affects 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
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 test data.
The complaints of patients with arterial hypertension are quite non-specific, so the diagnosis at the beginning of essential hypertension is considerably difficult.In most cases, during an episode of arterial hypertension, the patient is disturbed by a headache with a dominant localization in the frontal and occipital regions, severe dizziness, especially when changing the body position in space, and abnormal tinnitus.These manifestations are not pathognomonic, therefore it is not advisable to consider them as clinical criteria for arterial hypertension, since the above symptoms are periodically observed in completely healthy people and have nothing to do with increased blood pressure.The classical clinical manifestations in the form of respiratory disorders and signs of heart failure are observed only in the advanced stage of arterial hypertension.
Some etiopathogenetic forms of arterial hypertension are associated with the development of specific clinical symptoms, so an experienced specialist can establish the correct diagnosis during the initial examination and careful collection of the anamnesis.For example, in the case of arterial hypertension of the renovascular type, there are always acute 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 patient's well-being with this pathology is extremely difficult.
Endocrine arterial hypertension, on the contrary, is characterized by a tendency to the 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 with this pathological condition are characterized by extreme psycho-emotional irritability.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 notice severe weakness and a dull, widespread headache.
Grades and stages of arterial hypertension
Determining the severity and intensity of the clinical manifestations of arterial hypertension, as well as the stage of development of the disease, is a prerequisite for choosing the appropriate 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 stage 1 arterial hypertension most often do not notice significant damage to their own health, since the blood pressure value in this situation does not exceed 159/99 mm.rt.Art.
Stage 2 arterial hypertension 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.rt.Art.
The 3rd stage of the disease is characterized by an extremely serious aggressive course and a tendency to develop complications resulting from brain and heart dysfunctions.In the third degree, a critical increase in blood pressure exceeding 180/110 mm is observed.rt.Art.
In addition to the classification of arterial hypertension according to severity, in practice, cardiologists use the division of this pathology into stages, the criterion of which is the presence of signs of damage to target organs.
In the initial stages 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 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 the majority of cases, this stage of arterial hypertension in the form of hypertrophic cardiomyopathy of the left ventricle of the heart is established on the basis of echocardioscopy and ECG, the presence of narrowing of retinal arterial vessels and changes in parameters during the fundus examination, as well as a moderate increase in the plasma biochemical blood level, a moderate increase in the plasma blood level.
The third stage of arterial hypertension is terminal, in which the patient experiences 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 in the heart muscle, which manifests itself in the formation of infarct zones.Arterial hypertension has a negative effect on brain structures in the form of transient ischemic attacks, hypertensive encephalopathy, and even ischemic stroke foci.A persistent systemic increase in intravascular pressure has an extremely negative effect on the structure of the fundus vessels, resulting in retinal hemorrhages and swelling of the optic nerve head.
The terminal development stage of arterial hypertension is characterized by a significant suppression of kidney function, which is reflected in a creatinine level exceeding 177 µmol/l.
Diagnosis of arterial hypertension
During the clinical and instrumental-laboratory examination of patients with arterial hypertension, the main goal is not so much to establish the fact of increased blood pressure, but rather to reveal the cause of the development of secondary arterial hypertension, signs of damage to internal organs, and to assess the presence of factors that threaten 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.An objective examination of a patient with arterial hypertension allows in some cases to determine the etiopathogenetic form of the disease, due to the detection of specific pathognomonic symptoms.Thus, in combination with abdominal obesity, hypertrichosis, hirsutism and a persistent increase in the diastolic blood pressure component, the endocrine nature of the disease (Itsenko-Cushing syndrome) should be assumed.In the case of pheochromocytoma with severe paroxysmal arterial hypertension, an increase in skin pigmentation can be observed in the axillary projection.The main diagnostic clinical criterion for renovascular arterial hypertension is the auscultation of a vascular murmur in the projection of the region around the umbilicus.
Laboratory research methods for arterial hypertension consist of the analysis of the patient's lipid profile, the determination of uric acid and creatinine as the main criteria for kidney failure, and the analysis of the patient's hormonal status.
A necessary condition for determining the stage of the disease is target organ damage, that is, the diagnosis of those organs in which irreversible changes develop due to the increase in blood pressure.Thus, electrocardiographic recording and ultrasound imaging, which are part of the standard screening of all patients with arterial hypertension, are used to investigate cardiac dysfunction and organ damage.The patient's fundus must be examined to detect retinopathy, which is mainly observed in cases of long-lasting severe arterial hypertension.As an instrumental method of examining the kidney and brain, it is advisable to use radiographic imaging methods that are not included in the list of mandatory 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 the maximum elimination of the risk of developing cardiac complications and mortality rates.In this regard, the treating physician's primary task is to completely eliminate the reversible (modifiable) risk factors present in the patient, and to further relieve arterial hypertension and the accompanying clinical manifestations with medication.There is a certain standard that means reaching the target blood pressure, the values of which should not exceed 140/90 mm Hg.
In which cases is it worth using antihypertensive therapy for arterial hypertension?In their practice, cardiologists use the developed classification, which includes the patient's "risk of developing cardiovascular complications."According to this classification, people with a high risk of cardiovascular complications combined with a critical increase in blood pressure receive combined treatment with lifestyle modification and drug correction.Medium- and low-risk patients are subject to dynamic monitoring for at least three months, and pharmacologic antihypertensive treatment should be used only if non-pharmacological correction methods have no effect.
The principles of drug correction of arterial hypertension are the gradual lowering of blood pressure to the target values using the minimum therapeutic dose of one or more antihypertensive drugs.In some situations, low-dose antihypertensive drug monotherapy can have a long-term positive effect in reducing arterial hypertension.Currently, the pharmaceutical market is full of a wide range of antihypertensive drugs, but the most popular are combined groups of drugs that have a prolonged antihypertensive effect (up to 24 hours).
In the case of arterial hypertension occurring for the first time, preference should be given to diuretics, which have a wide range of positive effects in preventing the development of cardiovascular complications, reducing mortality, and preventing the progression of hypertrophic changes in the left ventricle of the heart.The pharmacological effect associated with a slight decrease in blood pressure is caused by a decrease in the reabsorption of water and sodium, as well as a decrease in vascular resistance.
The choice of diuretic depends on the patient's existing accompanying diseases.Therefore, in case of arterial hypertension combined with signs of heart and kidney failure, duck diuretics should be preferred.With long-term use, thiazide diuretics can cause the development of a hypokalemic syndrome, so it is better to combine them with aldosterone antagonists.
In the event that the patient has signs of arterial hypertension in combination with tachyarrhythmias, anginal attacks and symptoms of congestive chronic cardiovascular failure, it is advisable to use the group of B-blockers as first-line drugs.The mechanism of the antihypertensive effect of these drugs is the reduction of cardiac output and the inhibition of 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 for stopping the B-blocker.
It is recommended to prescribe antihypertensive drugs belonging to the ACE inhibitor group to patients with arterial hypertension due to proteinuria.An absolute contraindication to the use of drugs belonging to the ACE inhibitor group is the patient's existing bilateral renal stenosis.Drugs belonging to the group of angiotensin II receptor antagonists have a similar antihypertensive effect, with the difference that they do not cause cough and angioedema, which significantly expands the scope of their use.
Drugs belonging to the group of calcium channel blockers have a pronounced antihypertensive effect, allowing the reduction of arterial hypertension by reducing the calcium content of the vessel wall.The category of prescription of drugs belonging to this group consists primarily of elderly patients who, along with arterial hypertension, show signs of ischemic myocardial damage, which manifests itself in the development of anginal attacks.In cardiology practice, only long-acting forms of calcium channel blockers are used, since short-acting calcium antagonists significantly increase the risk of acute myocardial infarction.
In the event that the patient's arterial hypertension is combined with a violation of the heart rhythm, it is advisable to use calcium antagonists belonging to the category of phenylalkylamines and benzothiazepine derivatives.The absolute contraindication of this drug category is the patient's heart failure, which is accompanied by a decrease in the ejection fraction below 45%.
We must separately consider the pharmacological relief of hypertensive crisis, when 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 the risk of death increases sharply in the case of a prolonged hypertensive crisis.If the patient has symptoms of a complicated hypertensive crisis, parenteral administration of antihypertensive drugs is preferable.Most classes of antihypertensive drugs are available in parenteral form.Usually, the blood pressure-lowering 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 there is no critical increase in blood pressure in this pathological condition.Oral administration of blood pressure-lowering drugs in appropriate dosages allows blood pressure to be reduced within a few hours and to maintain target levels in the future.Of course, there are currently many methods to alleviate the hypertensive crisis with medication, however, in order to avoid the development of complications, the planned antihypertensive therapy must be used regularly.
In cases where arterial hypertension develops in the patient secondary to the narrowing of the renal arteries, the basic treatment method is surgical correction of the narrowing and revascularization with angioplasty.Surgical procedures for renovascular arterial hypertension (bypass surgery, endarterectomy) are used only if there is a contraindication to the use of transluminal angioplasty.If the patient has signs of aggressive arterial hypertension caused by severe unilateral nephrosclerosis, the only treatment option is nephrectomy.
In the case of endocrine secondary arterial hypertension, a combination of surgical treatment (radical excision of the tumor substrate) and drug antihypertensive therapy is used (spironolactone 200 mg daily in case of primary aldosteronism, phentolamine 25 mg every 4 hours in case of pheochromocytoma).
Prevention of arterial hypertension
Adherence to 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 suffered from this pathology for a long time, but also for healthy individuals who may have signs of hypertension.
It is a scientifically proven fact that there is a direct correlation between an increase in blood pressure and an increase in body weight, therefore normalizing the body weight of a person suffering from arterial hypertension is the most important preventive measure.In addition, following the rules for correcting eating behavior helps prevent the progression of atherosclerotic vascular damage, which is one of the main causes of arterial hypertension.
Recent studies in the field of pharmacology have confirmed the beneficial effect of Omega-3 polyunsaturated fatty acids on the restoration of vascular tone, which can also be considered an effective method for preventing arterial hypertension.Based on these results, you should consume enough olive oil daily and sharply limit your intake of animal fats.
Of course, if you want to get rid of the manifestations of arterial hypertension, you should give up such bad habits as smoking and drinking alcoholic beverages, since nicotine and alcohol particles, even in microdoses, can increase intravascular blood pressure.
People who have already had an episode of arterial hypertension should, as a secondary preventive measure, measure their blood pressure daily, keep a special diary reflecting the effectiveness of the drug therapy used, and if the condition worsens or new clinical symptoms appear, report this to the attending physician immediately.
Arterial hypertension - which doctor can help?If you have or suspect you have high blood pressure, see a doctor, such as a cardiologist, endocrinologist, or nephrologist, right away.