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, occurring as an independent nosological entity or as a manifestation of another pathology present in the patient.
According to global statistics, the epidemiological situation regarding the incidence of arterial hypertension is unfavorable, since the share of this pathology in the structure of cardiological diseases reaches 30%.There is a clear association between the increased risk of developing signs and consequences of arterial hypertension with increasing age of the patient, and therefore the main category of increased risk consists of mature and elderly people.
Causes of arterial hypertension
The appearance of signs of hypertension in a patient may occur against the background of existing chronic diseases, then this is a secondary or symptomatic variant of arterial hypertension.In cases where arterial hypertension is of a primary nature and it is not possible to determine the cause of an increase in intravascular blood pressure even after a comprehensive examination of the patient, the term “hypertension”, which is an independent nosological form, should be used.
Primary arterial hypertension is observed in almost 90% of cases in the presence of elevated blood pressure, and the polyetiology of the development of this pathological condition is currently being studied.Thus, there are non-modifiable risk factors for arterial hypertension that cannot be avoided (sex, genetic determination and age), but these provoking factors are not dominant for 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, 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 origin of essential arterial hypertension are being considered, but they do not affect the tactics of patient management and the determination of 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 provoking an increase in blood pressure, positive treatment results in this case cannot be expected.
So, in the renovascular variant of symptomatic arterial hypertension, the main pathogenetic connection is the stenosis of the renal artery, 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, which provokes overproduction of renin, which indirectly affects the increase in 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 a background pathology for the development of secondary arterial hypertension, for example, coarctation of the aorta.
Symptoms of arterial hypertension
Clinical manifestations at the initial stage of 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 non-specific and therefore the diagnosis at the beginning of essential hypertension is considerably difficult.In most cases, during an episode of arterial hypertension, the patient is plagued by headaches with a predominant localization in the frontal and occipital regions, 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 regularly 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 etiopathogenetic forms of arterial hypertension are accompanied by the development of specific clinical symptoms, so an experienced specialist can make the correct diagnosis as part of an initial examination and careful anamnesis.For example, in 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 crisis course, however, the patient's well-being with this pathology is extremely difficult.
Endocrine arterial hypertension, on the other hand, 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 development of severe headaches, profuse sweating and rapid heartbeat.Patients in this pathological condition are characterized by extreme psycho-emotional excitability.The development of hypertensive crisis most often occurs at night and the duration of clinical manifestations is no more than an hour.Afterwards, patients notice severe weakness and dull, widespread headaches.
Grades and stages of arterial hypertension
Determination of 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 selecting an adequate treatment regimen.The classification of arterial hypertension of both primary and symptomatic origin is based on the degree of increase in the systolic and diastolic components of blood pressure.
Patients with stage 1 arterial hypertension usually do not notice any significant impairment in their own health, since 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 dysfunction of the brain and heart.In the third degree there is a critical increase in blood pressure over 180/110 mm.rt.Art.
In addition to classifying arterial hypertension by severity, cardiologists in practice use a graded classification of this pathology, the criterion for 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 does not show any signs of organic damage to tissues and organs that respond to increased blood pressure.
In the second stage of the disease, detailed clinical symptoms develop, the intensity of which directly depends on the severity of the damage to the internal organs.However, in most cases, this stage of arterial hypertension is detected on the basis of instrumental confirmation of organ damage in the form of hypertrophic cardiomyopathy of the left ventricle using echocardioscopy and ECG, narrowing of the retinal arterial vessels when examining the fundus and the presence of changes in the parameters of a biochemical blood test, namely a moderate increase in the level of plasma creatinine.
The third stage of arterial hypertension is fatal and the patient experiences the development of irreversible changes in all organs that respond to increased blood pressure.In relation to the heart, a person who suffers from hypertension for a long period of time develops ischemic damage to the myocardium, which is manifested in the formation of infarct zones.Arterial hypertension negatively affects brain structures, 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 fundal 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 a significant suppression of renal function, which is reflected in creatinine levels above 177 µmol/l.
Diagnosis of arterial hypertension
When conducting a clinical and instrumental laboratory examination of patients with arterial hypertension, the main goal should be not so much to establish the fact of increased blood pressure as to identify the cause of the development of secondary arterial hypertension and signs of damage to internal organs, and 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 the key to making the correct diagnosis and determining further treatment tactics.An objective examination of a patient with arterial hypertension in some cases allows determining the etiopathogenetic form of the disease by detecting specific pathognomonic signs.Therefore, in the presence of abdominal obesity in a patient in combination with hypertrichosis, hirsutism and a persistent increase in the diastolic component of blood pressure, an endocrine nature of the disease (Itsenko-Cushing syndrome) should be assumed.In pheochromocytoma, accompanied by severe paroxysmal arterial hypertension, an increase in skin pigmentation in the projection of the armpits is observed.The most important diagnostic clinical criterion for renovascular arterial hypertension is auscultation of vascular murmurs in the projection of the periumbilical region.
The scope of laboratory examination methods for arterial hypertension includes the analysis of the patient's lipid profile, the determination of uric acid and creatinine as the main criteria for renal dysfunction, as well as the analysis of the patient's hormonal status.
In order to determine the stage of the disease, the diagnosis of target organ damage, i.e. organs in which irreversible changes develop due to increased blood pressure, is a necessary prerequisite.Therefore, to examine the heart for dysfunction and organic damage, electrocardiography and ultrasound examinations are used, which are part of the standard screening examination of all patients with arterial hypertension.To detect retinopathy, which is observed primarily in long-term severe arterial hypertension, an examination of the patient's fundus is necessary.The use of radiation imaging procedures is recommended as an instrumental method for examining the kidneys and brain. Although they are not part of the mandatory catalog of diagnostic measures, they make early diagnosis considerably easier (computed tomography, magnetic resonance imaging).
Treatment of arterial hypertension
The basic modern approach to the treatment of arterial hypertension is to maximally eliminate the risk of cardiac complications and the mortality rate.The main task of the treating physician is to completely eliminate reversible (changeable) risk factors in the patient with further medical relief of arterial hypertension and the associated clinical manifestations.There is a certain standard that consists in achieving the target blood pressure limit, the values of which should not exceed 140/90 mmHg.
In which cases should antihypertensive therapy be used for arterial hypertension?Cardiologists use the developed classification in their practice, in which the patient's “risk of developing cardiovascular complications” is assessed.According to this classification, persons with a high risk of cardiac complications in combination with a critical increase in blood pressure are subject to a combined treatment of lifestyle changes and drug correction.Patients classified as moderate and low risk will undergo dynamic observation for at least three months.Only if the use of non-drug correction methods has no effect should drug treatment to lower blood pressure be resorted to.
The principles of drug correction of arterial hypertension consist in a gradual reduction in blood pressure to target values by using a minimum therapeutic dose of one or more antihypertensive drugs.In some situations, monotherapy with a low dose of an antihypertensive drug may have a long-term beneficial effect in relieving arterial hypertension.Currently, the pharmaceutical market is filled with a wide range of antihypertensive drugs, but the most popular are combination groups of drugs that have a prolonged antihypertensive effect (up to 24 hours).
As the drug of choice in a first episode of arterial hypertension, preference should be given to diuretics, which have a wide range of beneficial effects in the form of preventing the development of cardiovascular complications, reducing mortality, and preventing the progression of hypertrophic changes in the myocardium of the left ventricle.The pharmacological effect, accompanied by a slight decrease in blood pressure, is caused by a reduced reabsorption of water and sodium and a reduction in vascular resistance.
The choice of diuretic depends on the patient's existing comorbidities.Therefore, in arterial hypertension in combination with signs of cardiac and renal insufficiency, preference should be given to loop diuretics.Thiazide diuretics can cause the development of hypokalemic syndrome with prolonged use.Therefore, it is better to use them in combination with aldosterone antagonists.
In a situation where a patient has signs of arterial hypertension in combination with tachyarrhythmia, angina pectoris attacks and symptoms of congestive chronic cardiovascular insufficiency, it is advisable to use a group of B-blockers 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 dosage of the drug in this group can lead to a significant decrease in heart rate and bronchoconstriction, which is an absolute indication for discontinuing the B-blocker.
For patients suffering from arterial hypertension due to proteinuria, it is recommended to prescribe antihypertensive drugs from the group of ACE inhibitors.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 antihypertensive effect, with the only difference that they do not provoke the development of cough and angioedema, which significantly expands their scope of application.
Drugs from the group of calcium channel blockers have a pronounced hypotensive effect and allow relieving arterial hypertension by reducing the calcium content in the vascular wall.The category of prescribing drugs in this group consists mainly of elderly patients who, simultaneously with arterial hypertension, have signs of ischemic myocardial damage, manifested in the development of angina pectoris attacks.In cardiological practice, only long-acting forms of calcium channel blockers are used, as short-acting calcium antagonists significantly increase the risk of triggering an acute myocardial infarction.
In a situation where arterial hypertension in a patient is accompanied by a violation of cardiac rhythm, it is advisable to use calcium antagonists of the phenylalkylamine category 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 the ejection fraction of less than 45%.
Separately, we should consider drug relief of 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 the risk of death increases sharply if a hypertensive crisis lasts for a long time.If the patient has signs of complicated hypertensive crisis, parenteral administration of drugs with antihypertensive effects is preferable.Most groups of antihypertensive drugs are available in parenteral form.As a rule, the antihypertensive effect occurs no later than 5 minutes after administration of the drug.
In the case of an uncomplicated hypertensive crisis, the use of parenteral antihypertensive drugs is not necessary, since in this pathological condition there is no critical increase in blood pressure.By administering antihypertensive medications orally in sufficient doses, you can lower blood pressure within a few hours and maintain the target values in the future.Of course, there are currently many methods for medical relief of a hypertensive crisis.However, in order to avoid the development of complications, planned antihypertensive therapy should be used regularly.
In cases where arterial hypertension in a patient is secondary and develops as a result of stenosis of the renal arteries, the basic method of treatment is surgical correction of the stenosis and revascularization using angioplasty.Surgical interventions for renovascular arterial hypertension (bypass surgery, endarterectomy) are only used 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.
In endocrine secondary arterial hypertension, a combination of surgical treatment (radical removal 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 arterial hypertension
Compliance with preventive measures, the action of which is aimed at preventing episodes of increased intravascular blood pressure and 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 experience signs of hypertension.
It has been scientifically proven that there is a direct connection between an increase in blood pressure and an increase in a person's body weight.Therefore, normalizing the weight of a person suffering from arterial hypertension is the primary preventive measure.In addition, compliance with the rules for correcting eating behavior will help 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 positive effect of omega-3 polyunsaturated fatty acids on restoring vascular tone, which can also be considered an effective method of preventing arterial hypertension.Based on these findings, you should consume olive oil in sufficient quantities every day and severely limit 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, since nicotine and alcohol particles can increase intravascular blood pressure even in microdoses.
Persons who have already had episodes of arterial hypertension should, as a secondary preventive measure, measure blood pressure daily, keep a special diary of the effectiveness of the drug therapy used, and if the condition worsens and new clinical manifestations appear, immediately report this to the attending physician.
Arterial hypertension – which doctor can help?If you have arterial hypertension or suspect that arterial hypertension is developing, you should immediately seek advice from doctors such as a cardiologist, endocrinologist and nephrologist.