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, 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 cardiac diseases reaches 30%.There is a clear correlation between the increased risk of developing signs and consequences of arterial hypertension with increasing patient age, and therefore the main category of increased risk is mature and elderly people.
Causes of arterial hypertension
The appearance of signs of hypertension in a patient can occur against the background of existing chronic diseases, and therefore 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 causing 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 increased existing blood pressure, and the polyetiology of the development of this pathological condition is currently being studied.There are therefore non-modifiable risk factors for arterial hypertension that cannot be avoided (sex, genetic determination 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).Taken together, all of 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 considered, although these hypotheses have no impact on the tactics of patient management 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 causing an increase in blood pressure, in this case one should not expect positive results of treatment.
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.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, causing overproduction of renin, which has an indirect effect on increasing 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 syndrome and pheochromocytoma.Some cardiovascular diseases can serve as an underlying 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 development of arterial hypertension can be completely absent, and the diagnosis in this case is based only on the data of an objective and instrumental laboratory examination.
The complaints presented by patients suffering from arterial hypertension are rather nonspecific and therefore, at the onset of essential hypertension, the diagnosis is considerably difficult.In most cases, during an episode of arterial hypertension, the patient is disturbed by headaches with 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 recommended to consider them clinical criteria for arterial hypertension, since the above symptoms are periodically observed in absolutely 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 the advanced stage of arterial hypertension.
Some etiopathogenic forms of arterial hypertension are accompanied by the development of specific clinical symptoms and therefore an experienced specialist can establish the correct diagnosis during an initial examination and careful collection of the medical history.For example, with 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 critical 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 towards 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 in the development of a severe headache, heavy sweating and rapid heartbeat.Patients in this pathological condition are characterized by extreme psycho-emotional excitability.The development of a hypertensive crisis occurs most often at night, and the duration of clinical manifestations does not exceed more than one hour, after which patients note severe weakness and dull, diffuse 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 selecting an adequate therapeutic 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 stage 1 arterial hypertension very often do not notice significant harm to their health due to the fact that blood pressure values in this situation do not exceed 159/99 mm.rt.Art.
Stage 2 arterial hypertension is accompanied by pronounced clinical manifestations and organic changes in target organs, and blood pressure indicators fall 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 due to brain and heart dysfunction.In the third degree there is a critical increase in blood pressure above 180/110 mm.rt.Art.
In addition to classifying arterial hypertension according to severity, in practice cardiologists use a gradual division of this pathology, the criterion of which is the presence of signs of damage to target organs.
In the initial phase of arterial hypertension of both primary and secondary origin, the patient presents absolutely no manifestations of organic damage to the tissues and organs sensitive to the increase in 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 the 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.In relation to the heart, a person who has been suffering from high blood pressure for a long time develops ischemic damage to the myocardium, which manifests itself in the formation of infarction 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 intravascular pressure has an extremely negative effect on the structure of the fundus vessels, which causes 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 significant suppression of renal function, which is reflected in creatinine levels, which exceed 177 µmol/l.
Diagnosis of arterial hypertension
When carrying out a clinical and instrumental laboratory examination on patients with arterial hypertension, the main goal should not be so much to establish the fact of increased blood pressure, but rather to find out the cause of the development of secondary arterial hypertension, signs of damage to internal organs, as well as 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 medical history.The objective examination of a patient suffering from arterial hypertension, in some cases, allows us to determine the etiopathogenetic form of the disease, thanks to the detection of specific pathognomonic signs.Therefore, with the abdominal type of obesity existing in a patient, combined with hypertrichosis, hirsutism and a persistent increase in the diastolic component of blood pressure, one should assume the endocrine nature of the disease (Itsenko-Cushing syndrome).With pheochromocytoma, accompanied by severe paroxysmal arterial hypertension, increased skin pigmentation is observed in the projection of the armpits.The main clinical diagnostic criterion for renovascular arterial hypertension is considered to be auscultation of the vascular bruit in the projection of the periumbilical region.
The purpose of laboratory research methods for arterial hypertension is to analyze the patient's lipid profile, determine uric acid and creatinine as the main criteria for renal dysfunction, and analyze the patient's hormonal status.
To determine the stage of the disease, a necessary condition is the diagnosis of damage to target organs, that is, organs in which irreversible changes develop due to increased blood pressure.Therefore, to examine the heart for dysfunction and organic damage, electrocardiographic recording and ultrasound are used, which are part of the standard screening examination of all patients suffering from arterial hypertension.To detect retinopathy, which is mainly observed in severe long-term 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 a correct diagnosis (computed tomography, magnetic resonance imaging).
Treatment of arterial hypertension
The fundamental modern approach to the treatment of arterial hypertension is to achieve maximum elimination of the risk of developing cardiac complications and mortality rates.In this regard, the primary task of the treating doctor is the complete elimination of the reversible (modifiable) risk factors present in the patient, with further pharmacological relief of arterial hypertension and the clinical manifestations that accompany it.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 which cases is it appropriate to use antihypertensive therapy for arterial hypertension?Cardiologists in their practice use the developed classification, which involves assessing 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 are subjected to combined treatment with lifestyle modification and drug correction.Patients classified as moderate and low risk are subject to dynamic observation for at least three months and only if no effect is found from the use of non-pharmacological correction methods should pharmacological antihypertensive treatment be resorted to.
The principles of pharmacological correction of arterial hypertension consist in a gradual reduction of blood pressure to target values using a minimum therapeutic dose of one or more antihypertensive drugs.In some situations, monotherapy with a low dose of antihypertensive drug can have a long-term positive effect in terms of reducing arterial hypertension.Currently, the pharmaceutical market is filled with a wide range of antihypertensive drugs, but the most popular are combined groups of drugs that have a prolonged (up to 24 hours) hypotensive effect.
As drugs of choice for the first episode of arterial hypertension, preference should be given to diuretics that have a wide range of positive effects in the form of prevention of the development of cardiovascular complications, reduction of mortality and prevention of the progression of hypertrophic changes in the myocardium of the left ventricle of the heart.The pharmacological effect, accompanied by a slight drop in blood pressure, is caused by 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 concomitant diseases.Therefore, in case of arterial hypertension associated with signs of cardiac and renal 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 a 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 first-line drugs.The antihypertensive mechanism of action of these drugs is to reduce cardiac output and inhibit renin production.It should be borne in mind that failure to comply with the dosage of the drug in this group can result in a marked decrease in heart rate and bronchoconstriction, which is an absolute indication for discontinuation of the B-blocker.
Patients suffering from arterial hypertension due to proteinuria are advised 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 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.
Medicines from the group of calcium channel blockers have a pronounced hypotensive effect, allowing you 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, simultaneously with arterial hypertension, show signs of ischemic myocardial damage, manifested in the development of angina attacks.In cardiology practice, only long-acting forms of calcium channel blockers are used because short-acting calcium channel blockers significantly increase the risk of causing 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 channel blockers 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 less than 45%.
Separately, we should consider pharmacological relief of hypertensive crisis, in which a critical increase in intravascular pressure and an acute course of arterial hypertension occurs.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 significantly.If the patient presents signs of complicated hypertensive crisis, the parenteral route of administration of drugs that have 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 a simple 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 adequate dosage 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 alleviating hypertensive crisis, however, to avoid the development of complications, it is necessary to regularly apply a planned regimen of antihypertensive therapy.
In cases where arterial hypertension in a patient is secondary and develops due to stenosis of the renal arteries, the basic treatment method is surgical correction of the stenosis and revascularization by 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 excision of the tumor substrate) and antihypertensive drug therapy (spironolactone at a daily dose of 200 mg for primary aldosteronism, phentolamine at 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 have been suffering from this pathology for a long time, but also for healthy individuals who may show signs of hypertension.
A scientifically proven fact is a direct correlation between the increase in blood pressure values and the increase in body weight of a person, and therefore the normalization of the weight of a person suffering from arterial hypertension is the main priority preventive measure.Furthermore, compliance with the rules to correct eating behavior helps prevent the progression of atherosclerotic vascular damage, which is one of the main causes of the development of arterial hypertension.
Recent pharmacological studies have demonstrated the beneficial effects of Omega-3 polyunsaturated fatty acids on the restoration of vascular tone, which can also be considered an effective method for preventing arterial hypertension.In light of these findings, you should consume olive oil in sufficient quantities every day and drastically limit your intake of animal fats.
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, 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 it to the attending physician.
Arterial hypertension – which doctor will help?If you have or suspect the development of high blood pressure, you should immediately seek advice from doctors such as a cardiologist, endocrinologist and nephrologist.