Arterial hypertension is a pathological or physiological tendency for a sharp or gradual increase in both the systolic and diastolic blood pressure components of intravascular blood pressure, occurring as an independent pathological unit or as a manifestation of another disease present in the patient.
According to global statistics, the epidemiological situation of the incidence of arterial hypertension is unfavorable, because the rate of this pathology in the structure of cardiovascular diseases is up to 30%.There is a clear correlation between the increasing risk of developing signs and consequences of arterial hypertension with increasing age of the patient, and therefore the main increased risk groups include adults and the elderly.
Causes of arterial hypertension
The appearance of signs of high blood pressure in a patient can occur based on existing chronic diseases, and then 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 the patient cannot determine the cause of intravascular hypertension, the term “hypertension” should be used, which is an independent pathological form.
Primary arterial hypertension is observed in almost 90% of existing cases of hypertension and the diverse causes of the development of this pathological condition are currently being considered.So, there are non-modifiable risk factors for arterial hypertension that are unavoidable (gender, genetic determination and age), however, these provoking factors do not prevail 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 exercise, psychological instability).Taken together, all of the above stimulating factors sooner or later create favorable conditions for the development of hypertension.
Currently, many pathophysiological theories of the development of primary arterial hypertension are being considered, although these hypotheses do not have any impact on the tactics of patient management and determining the scope of therapeutic measures.To a greater extent, it is necessary to take into account the cause that caused the development of secondary hypertension, since without eliminating the etiological factor that caused hypertension, in this case one should not expect positive results of treatment.
Therefore, in the vascular remodeling 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 etiologic factor affecting the renal arteries is systemic vasculitis.The consequence of stenosis is the development of ischemic damage in 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 pathological form of arterial hypertension is an increase in the level of hormonal substances that stimulate intravascular hypertension, which occurs in Itsenko-Cushing syndrome, Conn syndrome and pheochromocytoma.Some cardiovascular diseases can act 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 early stages of development of arterial hypertension may be completely absent, and the diagnosis in this case is based only on objective and instrumental examination data in the laboratory.
The complaints of patients with arterial hypertension are quite nonspecific, and therefore, at the onset of essential hypertension, diagnosis is very difficult.In most cases, during the period of arterial hypertension, the patient feels discomfort with headaches with localization mainly in the frontal and occipital regions, severe dizziness, especially when changing the body position in space, and pathological tinnitus.These manifestations are not pathological, therefore they should not be considered 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.Classic clinical manifestations in the form of respiratory disorders and signs of cardiac dysfunction are observed only in the advanced stages of hypertension.
Some forms of etiological arterial hypertension are accompanied by the development of specific clinical symptoms, and therefore an experienced specialist can make an accurate diagnosis during the initial examination and careful history taking.For example, with the regenerative type of arterial hypertension, there is always an acute onset of clinical manifestations, including a sharp and persistent increase in blood pressure, mainly due to the diastolic component.Renal arterial hypertension is not characterized by a crisis period, however, the health of patients with this pathology is extremely difficult.
In contrast, endocrine arterial hypertension is characterized by a tendency for 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 includes the development of severe headaches, profuse sweating, and tachycardia.Patients with this pathological condition are characterized by extreme psycho-emotional excitability.The development of hypertensive crisis usually occurs at night and the duration of clinical manifestations does not exceed one hour, after which the patient notices severe weakness and a dull, widespread headache.
Degrees and stages of arterial hypertension
Determining the level and intensity of clinical manifestations of hypertension as well as the stage of disease development are prerequisites for choosing an appropriate treatment regimen.The division of arterial hypertension of primary and symptomatic origin is based on the degree of increase in systolic and diastolic blood pressure components.
Patients with stage 1 arterial hypertension usually do not notice a significant deterioration in their health because blood pressure figures 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, blood pressure index is in the range of 179/109 mm.rt.Art.
Stage 3 of the disease is characterized by an extremely severe course and a tendency to develop complications due to dysfunction of the brain and heart.In the third degree, blood pressure increases beyond 180/110 mm.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 in target organs.
In the early stages of primary and secondary arterial hypertension, patients absolutely do not show signs 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 depends directly on the severity of damage to internal organs.However, in most cases, this stage of arterial hypertension is established on the basis of confirmation of organ damage in the form of hypertrophic cardiomyopathy of the left ventricle by echocardiography and ECG, narrowing of the retinal artery blood vessels on fundus examination and the presence of changes in the parameters of biochemical blood tests, in particular, a moderate increase in the concentration of creatinine in the blood plasma.
The third stage of arterial hypertension is the final stage, in which the patient experiences the development of irreversible changes in all organs sensitive to increased blood pressure.Regarding the heart, people with long-term high blood pressure will suffer heart muscle damage due to ischemia, manifested in the formation of infarct areas.Arterial hypertension has a negative impact on brain structure in the form of provoking transient ischemic attacks, hypertensive encephalopathy and even the formation of ischemic stroke foci.A long-term increase in systemic intravascular pressure has an extremely negative effect on the structure of the fundus blood vessels, leading to the formation of hemorrhages in the retina and swelling of the optic nerve head.
The final stage of the development of arterial hypertension is characterized by significant suppression of renal function, reflected in creatinine levels exceeding 177 µmol/l.
Diagnosis of arterial hypertension
When conducting clinical examination and instrumental tests of hypertensive patients, the main goal is not to determine the fact of hypertension, but to discover the causes of the development of secondary hypertension, signs of damage to internal organs, as well as evaluate the presence of risk factors for the development of cardiac complications.
During the first contact with the patient, the key to making an accurate diagnosis and determining further treatment tactics is the careful collection of patient history data.In some cases, objective examination of a patient with arterial hypertension allows us to determine the etiological form of the disease by detecting specific pathological signs.Therefore, given the existing abdominal obesity in the patient, combined with hirsutism, hirsutism and persistent increase in the diastolic blood pressure component, one should assume the endocrine nature of the disease (Itsenko-Cushing syndrome).With pheochromocytoma, accompanied by severe paroxysmal arterial hypertension, an increase in skin pigmentation is observed in the axillary protrusion.The main diagnostic clinical criterion for renal arterial hypertension is considered to be auscultation of a vascular bruit in the projection of the periumbilical area.
The scope of laboratory research methods on arterial hypertension includes 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.
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 hypertension.Therefore, to examine the heart for dysfunction and organic damage, electrocardiography and ultrasound are used, which are part of the standard screening examination for all patients with arterial hypertension.To detect retinopathy, which occurs mainly in patients with severe persistent arterial hypertension, it is necessary to examine the patient's fundus.As instrumental methods for studying the kidneys and brain, it is recommended to use radiographic methods, which are not included in the list of mandatory diagnostic measures, but greatly facilitate the early establishment of an accurate diagnosis (computed tomography, magnetic resonance imaging).
Treatment of arterial hypertension
The basic modern approach to the treatment of arterial hypertension is to achieve the goal of maximum elimination of the risk of developing cardiac complications and mortality.In this regard, the main task of the treating physician is to completely eliminate the reversible (modifiable) risk factors present in the patient, and to further reduce arterial hypertension and its accompanying clinical manifestations.There is a certain standard that includes achieving target blood pressure limits, which should not exceed 140/90 mmHg.
In what cases should antihypertensive drugs be used to treat arterial hypertension?Cardiologists in their practice use the developed classification, which includes assessing the patient's “risk of developing cardiovascular complications”.According to this classification, people at high risk of heart complications combined with severe hypertension must be treated with a combination of lifestyle changes and medication adjustments.Patients classified as intermediate and low risk should be followed dynamically for at least three months and only if the use of non-pharmacological management methods has been ineffective should pharmacological antihypertensive treatment be used.
The principle of drug adjustment for arterial hypertension includes gradually reducing blood pressure to the target value using the minimum therapeutic dose of one or more antihypertensive drugs.In some cases, monotherapy with low-dose antihypertensive agents may have a positive long-term effect in reducing arterial blood pressure.Currently, the pharmaceutical market is flooded with many types of antihypertensive drugs, but the most popular are combination drugs with long-lasting antihypertensive effects (up to 24 hours).
As the drug of choice for the first episode of arterial hypertension, preference should be given to diuretics that have many 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 due to a decrease in water and sodium reabsorption and a decrease in vascular resistance.
The choice of diuretic depends on the patient's existing comorbidities.Therefore, in cases of arterial hypertension combined with signs of heart failure and renal failure, priority should be given to the use of loop diuretics.Thiazide diuretics with long-term use can cause hypokalemia syndrome, and therefore it is better to use them in combination with aldosterone antagonists.
In situations where the patient has signs of arterial hypertension combined with tachyarrhythmia, angina pectoris and symptoms of chronic congestive heart failure, group B blockers should be used as first-line drugs.The mechanism of antihypertensive action of these drugs is to reduce cardiac output and inhibit renin production.It should be borne in mind that non-compliance with the drug dosage in this group can lead to a decrease in heart rate and marked bronchospasm, which is an absolute indication for discontinuation of B-blockers.
For patients with arterial hypertension caused by proteinuria, antihypertensive drugs belonging to the group of ACE inhibitors should be prescribed.An absolute contraindication to the use of drugs from 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 hypotensive effect, the only difference is that they do not cause cough and angioedema, which significantly expands the scope of their use.
The drug belongs to the group of calcium channel blockers and has a clear antihypertensive effect, helping to reduce arterial hypertension by reducing the calcium content in the vessel walls.The group prescribing drugs in this group mainly includes elderly patients who also suffer from arterial hypertension, signs of ischemic myocardial damage, manifested in the development of angina attacks.In cardiovascular 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 case of arterial hypertension in patients combined with arrhythmias of cardiac activity, calcium antagonists of the phenylalkylamine group and benzothiazpine derivatives should be used.An absolute contraindication to the use of this drug is the patient's current heart failure, accompanied by a reduced ejection fraction below 45%.
Separately, we should consider medication to reduce a hypertensive crisis, which involves a severe increase in intravascular pressure and an acute episode of arterial hypertension.In this situation, priority should be given to drugs with a pronounced antihypertensive effect, because when the hypertensive crisis lasts, the risk of death increases sharply.If the patient shows signs of a complicated hypertensive crisis, drugs with a hypotensive effect should be administered by injection.Most classes of antihypertensive drugs are available in injectable form.As a rule, the hypotensive effect occurs no later than 5 minutes after taking the drug.
In the case of uncomplicated hypertensive crisis, there is no need to use injectable forms of antihypertensive drugs, because in this pathological condition there is no serious increase in blood pressure.Taking oral antihypertensive medications in appropriate doses allows you to reduce your blood pressure within a few hours and maintain the target level in the future.Of course, today there are many pharmacological methods to reduce hypertensive attacks, however, to avoid the development of complications, a planned antihypertensive treatment regimen should be regularly applied.
In cases where the patient's arterial hypertension is secondary and develops due to renal artery stenosis, the basic treatment is surgical correction of the stenosis and revascularization by angioplasty.Surgical procedures to treat renovascular hypertension (bypass surgery, endarterectomy) should only be used if there are contraindications to the use of transluminal coronary angioplasty.If the patient has signs of severe arterial hypertension due to severe unilateral nephrosclerosis, the only treatment method is nephrectomy.
For secondary endocrine arterial hypertension, a combination of surgical treatment (radical resection of the tumor stroma) and pharmacological antihypertensive treatment (Spironolactone at a dose of 200 mg daily for primary hyperaldosteronism, 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 intravascular hypertension, 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 people who may experience signs of high blood pressure.
It is a scientifically proven fact that there is a direct correlation between an increase in blood pressure and an increase in a person's body weight, and therefore, normalizing the weight of a person with arterial hypertension is a priority preventive measure.In addition, compliance with the rules that regulate dietary behavior helps prevent the progression of vascular damage due to atherosclerosis, one of the main causes of the development of arterial hypertension.
Recent studies in the field of pharmacology have demonstrated the beneficial effect of Omega-3 polyunsaturated fatty acids in restoring vascular tone, which can also be considered an effective method for preventing arterial hypertension.With these findings, you should consume olive oil in sufficient amounts every day and minimize 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 particles and alcohol, even in micro doses, can increase intravascular blood pressure.
People who have had arterial hypertension, as a secondary prevention measure, should measure blood pressure daily, keep a special diary reflecting the effectiveness of treatment with the drugs used, and if the condition worsens and new clinical manifestations appear, immediately notify the attending physician.
Arterial hypertension – which doctor will help?If you have or suspect the development of arterial hypertension, you should seek immediate advice from doctors such as a cardiologist, endocrinologist and nephrologist.