Arterial hypertension is a pathological or physiological predisposition to a sudden or progressive increase in the systolic and diastolic components of intravascular blood pressure, appearing as an independent nosological unit or as the manifestation of another pathology present in the patient.
According to world 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 developing signs and consequences of high blood pressure with the age of the patient, and therefore the main category of increased risk is middle-aged and elderly people.
Causes of high blood pressure
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 high blood pressure.In cases where arterial hypertension is of a primary nature and even after a complete examination of the patient it is not possible to determine the cause provoking an increase in intravascular blood pressure, it is appropriate to use the term "hypertension", which is an independent nosological form.
Primary arterial hypertension is observed in almost 90% of cases of existing arterial hypertension, and the polyetiology of the development of this pathological condition is currently being studied.Thus, there are non-modifiable risk factors for high blood pressure, which cannot be avoided (sex, genetic determination and age), however, these provoking factors are not dominant in the development of severe high blood pressure.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 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 caring for patients 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, because without eliminating the etiological factor that causes an increase in blood pressure, positive results from treatment should not be expected in this case.
Thus, in the renovascular variant of symptomatic arterial hypertension, the main pathogenetic link is renal artery stenosis, 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 hyperproduction 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 increasing intravascular blood pressure, which occurs in Itsenko-Cushing syndrome, Conn syndrome and pheochromocytoma.Some cardiovascular diseases can serve as a background pathology for the development of secondary arterial hypertension, for example, coarctation of the aorta.
Symptoms of high blood pressure
Clinical manifestations at the initial stage of the development of arterial hypertension may be completely absent, and the diagnosis in this case is based solely on the data of an objective and instrumental laboratory examination.
The complaints made by patients with arterial hypertension are quite nonspecific, and therefore, in the early stages of essential hypertension, the diagnosis is very difficult.In most cases, during an episode of arterial hypertension, the patient is bothered by a headache with a predominant localization in the frontal and occipital region, severe dizziness especially when changing body position in space and pathological 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 an increase in blood pressure.Classic clinical manifestations in the form of respiratory disturbances 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 anamnesis.For example, with arterial hypertension of the renovascular type, there is always an acute onset of clinical manifestations, consisting of a critical and constant sharp 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 patient's clinical “paroxysmal triad”, which consists of the appearance of a severe headache, profuse sweating and rapid heartbeat.Patients with 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 an hour, after which patients notice severe weakness and a dull, generalized headache.
Degrees and stages of high blood pressure
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 primary and symptomatic origin is based on the level of increase in the systolic and diastolic components of blood pressure.
Patients suffering from stage 1 arterial hypertension most often do not notice a significant deterioration in their own health, since the blood pressure figures in this situation do not exceed 159/99 mm.art.Art.
Stage 2 arterial hypertension is accompanied by pronounced clinical manifestations and organic changes in target organs, and blood pressure indicators are in the range of 179/109 mm.art.Art.
Stage 3 of the disease is characterized by an extremely severe aggressive course and a tendency to develop complications due to dysfunction of the brain and heart.In the third degree, a critical increase in blood pressure exceeding 180/110 mm is observed.art.Art.
In addition to classifying arterial hypertension by severity, in practice cardiologists use a stage division of this pathology, the criterion of which is the presence of signs of target organ damage.
At the initial stage of arterial hypertension of 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 damage to internal organs.However, in most cases, this stage of arterial hypertension is established on the basis of instrumental confirmation of organic 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, during which the patient undergoes the development of irreversible changes in all organs sensitive to increased blood pressure.As for the heart, a person who has suffered from high blood pressure for a long time develops ischemic damage to the myocardium, which is manifested by 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 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 leads to the formation of hemorrhages in the retina and swelling of the optic nerve head.
The end stage of the 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 high blood pressure
During a clinical and instrumental laboratory examination of patients with arterial hypertension, the main goal should not so much be to establish the fact of an increase in 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 to assess the presence of risk factors for the development of cardiac complications.
During the first contact with the patient, careful collection of the patient's anamnestic data is essential for establishing the correct diagnosis and determining subsequent treatment tactics.Objective examination of a patient suffering from arterial hypertension makes it possible, in certain cases, to determine the etiopathogenetic form of the disease, thanks to the detection of specific pathognomonic signs.So, with the type of abdominal obesity existing in a patient, associated 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 diagnostic clinical criterion of renovascular arterial hypertension is considered to be auscultation of vascular murmur in the projection of the periumbilical region.
The scope of laboratory research methods for arterial hypertension consists of analyzing the patient's lipid profile, determining uric acid and creatinine as the main criteria for renal dysfunction, and analyzing the patient's hormonal state.
In order to determine the stage of the disease, a necessary condition is the diagnosis of target organ damage, that is, those organs in which irreversible changes develop due to increased blood pressure.So, to examine the heart for malfunctions and organ damage, electrocardiographic recording and ultrasound imaging are used, which are part of the standard screening examination of all patients with high blood pressure.In order to detect retinopathy, which is mainly seen in cases of severe long-term high blood pressure, it is necessary to examine the patient's fundus.As instrumental methods for studying the kidneys and brain, it is advisable to use radiological imaging methods, which are not included in the obligatory list of diagnostic measures, but greatly facilitate the early establishment of a correct diagnosis (computed tomography, magnetic resonance imaging).
Treatment of high blood pressure
The fundamental modern approach to the treatment of high blood pressure is to eliminate the risk of developing heart complications and mortality rates as much as possible.In this regard, the main task of the attending physician is the complete elimination of reversible (modifiable) risk factors present in the patient, with additional drug relief of arterial hypertension and accompanying clinical manifestations.There is a certain standard, which involves reaching the target limit of blood pressure, the values of which should not exceed 140/90 mmHg.
In which cases should antihypertensive treatment be used for high blood pressure?Cardiologists in their practice use the developed classification, which involves assessing the patient's “risk of developing cardiovascular complications”.According to this classification, people with a high risk of cardiac complications associated with a critical increase in blood pressure are subject to combined treatment using 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 there is no effect from the use of non-drug methods of correction should drug antihypertensive therapy be resorted to.
The principles of drug correction of arterial hypertension consist of 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 an antihypertensive drug can have a positive long-term effect in terms of relieving high blood pressure.Currently, the pharmaceutical market is replete with a wide range of antihypertensive drugs, but the most popular are combined groups of drugs with a prolonged (up to 24 hours) hypotensive effect.
As drugs of choice for a first episode of arterial hypertension, preference 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 depends on the patient's existing concomitant diseases.Therefore, in the event of high blood pressure associated with signs of heart and kidney failure, loop diuretics should be preferred.Thiazide diuretics used long-term can cause the development of hypokalemic syndrome and therefore it is preferable to use them in combination with aldosterone antagonists.
In a situation where a patient has signs of high blood pressure associated with tachyarrhythmias, angina attacks and symptoms of chronic congestive cardiovascular insufficiency, 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 noted that non-compliance with the dosage of the drug in this group can cause a pronounced decrease in heart rate and bronchoconstriction, which is an absolute indication for discontinuation of the B-blocker.
For patients suffering from high blood pressure due to proteinuria, it is advisable 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, the only difference being that they do not cause 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, allowing to relieve high blood pressure by reducing the calcium content of the vascular wall.The category of drug prescription of this group is mainly elderly patients who, simultaneously with arterial hypertension, have signs of ischemic damage to the myocardium, manifested by the development of attacks of angina pectoris.In cardiological practice, only long-acting forms of calcium channel blockers are used, since short-acting calcium antagonists significantly increase the risk of causing acute myocardial infarction.
In a situation where high blood pressure in a patient is associated with a violation of the rhythm of cardiac activity, it is advisable 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 ejection fraction below 45%.
Separately, we should consider drug 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 a hypertensive crisis, the risk of death sharply increases.If the patient has signs of a complicated hypertensive crisis, the parenteral route of 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 a simple 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 an adequate dose allows you to reduce blood pressure within a few hours and maintain target levels in the future.Of course, there are currently many methods of drug relief of a hypertensive crisis.However, to avoid the development of complications, a planned antihypertensive treatment regimen should be regularly applied.
In cases where high blood pressure in a patient is secondary and develops as a result of stenosis of the renal arteries, the basic treatment method is surgical correction of stenosis and revascularization by angioplasty.Surgical interventions 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.
For secondary endocrine arterial hypertension, a combination of surgical treatment (radical excision of the tumor substrate) and drug antihypertensive therapy is used (Spironolactone at a daily dose of 200 mg for primary aldosteronism, Phentolamine at a dose of 25 mg every 4 hours for pheochromocytoma).
Prevention of high blood pressure
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 high blood pressure, is indicated not only for patients suffering from this pathology for a long time, but also for healthy people who may have signs of high blood pressure.
A scientifically proven fact is a direct correlation between increased blood pressure and increased body weight of a person.Therefore, normalizing the weight of a person suffering from high blood pressure is the main priority preventive measure.In addition, compliance with the rules for correcting eating behavior helps prevent the progression of atherosclerotic vascular lesions, which are 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 on the restoration of vascular tone, which can also be considered an effective method for preventing high blood pressure.Given these findings, you must consume a sufficient quantity of olive oil daily and strongly limit your consumption of animal fats.
Of course, if you want to get rid of the manifestations of high blood pressure, you need to abandon bad habits such as smoking and drinking alcoholic beverages, because particles of nicotine and alcohol, even in microdoses, can increase intravascular blood pressure.
People who have previously had episodes of high blood pressure, as secondary preventive measures, should measure blood pressure daily, keep a special diary reflecting the effectiveness of the drug treatment used and, if the condition worsens and new clinical manifestations appear, immediately notify the attending physician.
High blood pressure – which doctor can help you?If you suffer from or suspect the development of high blood pressure, you should immediately seek advice from doctors such as a cardiologist, endocrinologist and nephrologist.