Arterial hypertension is a pathological or physiological predisposition to a marked or gradual increase in the systolic and diastolic components of intravascular blood pressure, occurring 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 cardiological diseases reaches 30%.There is a clear correlation between the increased risk of developing signs and consequences of high blood pressure with the increase in the patient's age and, therefore, the main category of increased risk consists of mature and elderly people.
Causes of high blood pressure
The appearance of signs of hypertension in a patient can occur against the background of 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 complete examination of the patient it is not possible to determine the cause that provokes 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 existing increased blood pressure, and the polyetiology of the development of this pathological condition is being considered.Thus, there are non-modifiable risk factors for high blood pressure, which cannot be avoided (gender, 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 the person's lifestyle (unbalanced diet, bad habits, sedentary lifestyle, psycho-emotional instability).Together, all of the above provoking factors sooner or later create favorable conditions for the pathogenetic development of arterial hypertension.
Currently, many pathogenetic theories about the development of essential arterial hypertension are being considered, although these hypotheses do not have an 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 that causes an increase in blood pressure, in this case, positive results from treatment should not be expected.
Thus, 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 in 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 an increase in intravascular blood pressure, which occurs in Itsenko-Cushing syndrome, Conn syndrome and pheochromocytoma.Some cardiovascular diseases can act as the underlying 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 only on the data of an objective and instrumental laboratory examination.
The complaints of patients with arterial hypertension are quite nonspecific, and therefore, at the onset of essential hypertension, the diagnosis is significantly difficult.In most cases, during an episode of arterial hypertension, the patient is bothered by a headache predominantly localized 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 advisable to consider them as clinical criteria for arterial hypertension, since the above symptoms are periodically observed in absolutely healthy people and have nothing to do with an increase in 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 etiopathogenetic 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, in arterial hypertension of the renovascular type, 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 crisis course, however, the well-being of patients with this pathology is extremely difficult.
Endocrine arterial hypertension, on the contrary, is characterized by a tendency towards 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 development of severe headache, intense sweating and tachycardia.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 more than an hour, after which patients notice severe weakness and a dull, generalized headache.
Degrees and stages of arterial hypertension
Determining the severity and intensity of the clinical manifestations of arterial hypertension, as well as the stage of disease progression, is a prerequisite for selecting an 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 often do not notice a significant impairment in their own 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 are in 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, a critical increase in blood pressure of more than 180/110 mm occurs.Rt. Art.
In addition to classifying arterial hypertension by severity, in practice, cardiologists use a staggered division of this pathology, the criterion of which is the presence of signs of damage to target organs.
At the initial stage of arterial hypertension of primary and secondary origin, the patient does not show 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 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.Regarding the heart, those who suffer from hypertension for a long time develop 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 foci of ischemic stroke.A prolonged systemic increase in intravascular pressure has an extremely negative effect on the structure of the fundus vessels, which results in the formation of retinal hemorrhages and swelling of the optic nerve head.
The terminal phase of the development of arterial hypertension is characterized by a significant suppression of renal function, which is reflected in creatinine levels, which exceed 177 µmol/l.
Diagnosis of high blood pressure
When carrying out clinical and instrumental-laboratory examination of patients with arterial hypertension, the main goal should not so much be to establish the fact of increased blood pressure as 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 initial patient contact, the key to establishing the correct diagnosis and determining new treatment tactics is the careful collection of the patient's anamnestic data.The objective examination of a patient with arterial hypertension, in some cases, makes it possible to determine the etiopathogenetic form of the disease, due to the detection of specific pathognomonic signs.Thus, with the patient's existing type of abdominal obesity, combined with hypertrichosis, hirsutism and a persistent increase in the diastolic component of blood pressure, the endocrine nature of the disease (Itsenko-Cushing syndrome) must be assumed.In 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 a vascular murmur in the projection of the periumbilical region.
The scope of laboratory methods for researching 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 status.
To determine the stage of the disease, a necessary condition is the diagnosis of target organ damage, that is, organs in which irreversible changes develop due to an increase in blood pressure.Thus, to examine the heart for dysfunction and organic damage, electrocardiographic and ultrasound recordings are used, which are part of the standard screening examination of all patients suffering from high blood pressure.To detect retinopathy, which is mainly observed in long-term severe arterial hypertension, it is necessary to examine the patient's background.As instrumental methods for studying the kidneys and brain, it is advisable to use radioimaging 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 high blood pressure
The fundamental modern approach to treating high blood pressure is to achieve maximum elimination of the risk of developing cardiac complications and mortality rates.In this sense, the main task of the attending physician is the complete elimination of the reversible (modifiable) risk factors present in the patient, with greater medication relief of arterial hypertension and concomitant clinical manifestations.There is a certain standard that consists of reaching the target blood pressure limit, whose values should not exceed 140/90 mmHg.
In what cases should antihypertensive therapy 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 in combination with a critical increase in blood pressure are subject to combined treatment with lifestyle modification and drug correction.Patients classified as moderate and low risk undergo dynamic observation for at least three months, and only if there is no effect from the use of non-drug correction methods, should drug antihypertensive treatment be resorted to.
The principles of drug correction of arterial hypertension consist of the gradual reduction of blood pressure to target values, through the use of a minimum therapeutic dose of one or more antihypertensive drugs.In some situations, low-dose monotherapy of an antihypertensive medication may have a positive long-term effect on relieving high blood pressure.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 (up to 24 hours) hypotensive effect.
As medications of choice for the first episode of arterial hypertension, preference should be given to diuretics that have a wide range of positive effects in terms 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 the reabsorption of water and sodium and a decrease in vascular resistance.
The choice of diuretic depends on the patient's existing concomitant diseases.Therefore, in the case of arterial hypertension associated with signs of heart and kidney failure, preference should be given to loop diuretics.Thiazide diuretics with prolonged 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 the patient presents 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 medications.The mechanism of antihypertensive action of these drugs is to reduce cardiac output and inhibit renin production.It must be taken into account that failure to comply with the medication dosage in this group can cause a marked decrease in heart rate and bronchoconstriction, which is an absolute indication for discontinuation of the B-blocker.
For patients suffering from arterial hypertension due to proteinuria, it is advisable to prescribe antihypertensive drugs from the ACE inhibitors group.An absolute contraindication to the use of drugs from the ACE inhibitor group is the patient's existing bilateral renal stenosis.Medicines 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, making it possible to relieve high blood pressure by reducing the calcium content in the vascular wall.The medication prescription category of this group is mainly made up of elderly patients who, simultaneously with arterial hypertension, show signs of ischemic myocardial damage, manifested in the development of angina attacks.In cardiological practice, only long-acting forms of calcium channel blockers are used due to the fact that short-acting calcium antagonists significantly increase the risk of provoking acute myocardial infarction.
In a situation where the patient's arterial hypertension 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 medications is the patient's existing heart failure, accompanied by a decrease in the ejection fraction of less than 45%.
Separately, we must 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 the hypertensive crisis, the risk of death increases sharply.If the patient shows signs of a complicated hypertensive crisis, the parenteral route of administration of medications with a hypotensive effect is preferable.Most groups of antihypertensive medications are available in parenteral form.As a rule, the hypotensive effect occurs no later than 5 minutes after taking the medication.
In the case of an uncomplicated 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 medications in adequate dosage 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 of medicinal relief from a hypertensive crisis;however, to prevent the development of complications, a planned regimen of antihypertensive therapy should be applied regularly.
In cases where the patient's arterial hypertension is secondary and develops as a result of stenosis of the renal arteries, the fundamental treatment method is surgical correction of the stenosis and revascularization by angioplasty.Surgical procedures for renovascular arterial hypertension (myocardial revascularization surgery, endarterectomy) are used only if there are contraindications to the use of transluminal angioplasty.If the patient shows 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 (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 high blood pressure
Compliance with preventive measures, the effect of which is aimed at preventing episodes of increased intravascular pressure, as well as reducing the risk of complications from arterial hypertension, is recommended not only for patients who have suffered from this pathology for a long time, but also for healthy individuals who may show signs of hypertension.
A scientifically proven fact is the 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 suffering from arterial hypertension is the main priority preventive measure.In addition, compliance with the rules for correcting eating behavior helps prevent the progression 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 effects of omega-3 polyunsaturated fatty acids in restoring vascular tone, which can also be considered an effective method in preventing high blood pressure.Given these findings, you should consume olive oil in sufficient quantities daily and drastically limit your intake of animal fats.
Of course, if you want to get rid of the manifestations of high blood pressure, you must abandon bad habits such as smoking and drinking alcoholic beverages, as nicotine and alcohol particles, even in microdoses, can increase intravascular pressure.
People who have already had episodes of high blood pressure, as secondary preventive measures, should measure their 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 notify the attending physician.
High blood pressure – which doctor will help?If you have or suspect the development of high blood pressure, you should immediately consult doctors such as a cardiologist, endocrinologist and nephrologist.