Arterial hypertension is a pathological or physiological tendency to a sharp 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 of the incidence of arterial hypertension is not optimistic, since the proportion of this pathology in cardiac structures reaches 30%.There is a clear correlation between the increased risk of developing symptoms and consequences of arterial hypertension as the patient ages, such that the main categories of increased risk include adults and the elderly.
causes of arterial hypertension
Signs of hypertension in patients may appear in the context of an existing chronic disease, and then we are talking about secondary or symptomatic arterial hypertension.If arterial hypertension is primary and the cause of the increase in intravascular blood pressure cannot be determined even after a thorough examination of the patient, the term "hypertension" should be used, which is an independent form of disease classification.
Essential arterial hypertension is observed in almost 90% of existing cases of elevated blood pressure, and a multi-etiology for the development of this pathological condition is currently under consideration.Therefore, there are unavoidable and unmodifiable risk factors for arterial hypertension (sex, genetic determination, and age), however, these predisposing factors are not dominant in the development of severe arterial hypertension.To a greater extent, the development of symptoms of essential arterial hypertension is influenced by a person's lifestyle (unbalanced diet, bad habits, lack of activity, psycho-emotional instability).In summary, all the above-mentioned predisposing factors sooner or later create favorable conditions for the development of arterial hypertension.
Currently, the pathogenesis of many forms of essential arterial hypertension is being considered, although these hypotheses have no impact on patient management strategies and defining the scope of therapeutic measures.To a greater extent, the pathogenesis of secondary arterial hypertension should be considered, since a positive therapeutic outcome should not be expected in this case without eliminating the cause of the increase in blood pressure.
Therefore, in the renovascular variant of symptomatic arterial hypertension, the main pathogenesis is renal artery stenosis, which occurs due to atherosclerotic lesions or fibromuscular dysplasia.An extremely rare cause affecting the renal arteries is systemic vasculitis.The consequence of stenosis is ischemic damage to one or both kidneys, causing excessive production of renin, which indirectly leads to an increase in blood pressure.
The pathogenesis of endocrine arterial hypertension is elevated levels of hormone substances that stimulate intravascular blood pressure and occurs in Itsenko-Cushing syndrome, Conn syndrome, and pheochromocytoma.Some cardiovascular diseases can serve as background pathologies in the development of secondary arterial hypertension, such as aortic coarctation.
Symptoms of arterial hypertension
Clinical manifestations in the early stages of the development of arterial hypertension may be completely absent, and the diagnosis in this case is based solely on data from objective and instrumental laboratory tests.
The complaints of patients with arterial hypertension are very nonspecific, making diagnosis very difficult during the onset of essential hypertension.In most cases, during an episode of arterial hypertension, patients are troubled by headaches mainly located in the frontal and occipital regions, severe dizziness (especially when changing body position in space), and pathological tinnitus.These manifestations are not specific and therefore are not recommended as clinical criteria for arterial hypertension, since the above symptoms are regularly observed in absolutely healthy people and are not associated with an increase in blood pressure.Typical clinical manifestations such as signs of respiratory disease and cardiac dysfunction are observed only in the advanced stages of arterial hypertension.
Some etiological forms of arterial hypertension are accompanied by the development of specific clinical symptoms, so an experienced specialist can make the correct diagnosis during a preliminary examination and careful collection of the history.For example, in renovascular arterial hypertension, there is always an acute onset of clinical manifestations, including acute, borderline, and sustained elevations in blood pressure primarily due to a diastolic component.Renovascular arterial hypertension is not characterized by a crisis course, however, the health status of patients with this pathology is extremely difficult.
In contrast, endocrine arterial hypertension is characterized by a tendency for the disease to have a paroxysmal course and develop into typical hypertensive crises.This pathology is characterized by patients' clinical "paroxysmal triad" of severe headache, severe sweating, and rapid heartbeat.Patients in this pathological state are characterized by extreme psychological and emotional excitement.Hypertensive crises most commonly occur at night, with clinical manifestations lasting less than one hour, after which the patient develops severe weakness and dull, generalized headache.
Degree and stage of arterial hypertension
Determining the severity and intensity of the clinical manifestations of arterial hypertension and the stage of development of the disease are prerequisites for selecting an appropriate treatment regimen.The classification of essential arterial hypertension and symptomatic arterial hypertension is based on the elevated levels of systolic and diastolic blood pressure.
Patients with stage 1 arterial hypertension usually do not notice significant damage to their health, since the blood pressure figures in this condition do not exceed 159/99 mm.RT.Art.
Stage 2 arterial hypertension is accompanied by obvious clinical manifestations and organic changes in target organs, and the blood pressure index is within the range of 179/109 mm.RT.Art.
The third stage of the disease is characterized by an extremely aggressive course and is prone to complications from brain and heart dysfunction.In the third degree, the blood pressure rises sharply to more than 180/110 mm.RT.Art.
In addition to classifying arterial hypertension by severity, in practice cardiologists also stage this pathology based on the presence or absence of signs of damage to target organs.
In the early stages of primary and secondary arterial hypertension, patients have no symptoms of organic damage to tissues and organs that are sensitive to elevated blood pressure.
The second stage of the disease involves the development of detailed clinical symptoms, the intensity of which depends directly on the severity of the damage to the internal organs.However, in most cases, arterial hypertension at this stage is determined on the basis of echocardiography and electrocardiography with instrumental confirmation of organ damage in the form of cardiac left ventricular hypertrophic cardiomyopathy, narrowing of the retinal arterial vessels during fundus examination, and changes in biochemical blood test parameters (ie, a moderate increase in plasma creatinine levels).
The third stage of arterial hypertension is the advanced stage, in which irreversible changes occur in all organs of the patient that are sensitive to elevated blood pressure.As far as the heart is concerned, people with long-term hypertension will develop ischemic damage to the myocardium, manifested as the formation of infarcted areas.Arterial hypertension negatively affects brain structure, manifesting as transient ischemic attacks, hypertensive encephalopathy, and even the formation of ischemic stroke lesions.Long-term elevated systemic intravascular pressure has an extremely negative impact on the structure of fundus vessels, leading to retinal hemorrhage and optic nerve head swelling.
The end stage of the development of arterial hypertension is characterized by a significant suppression of renal function, which is reflected in creatinine levels exceeding 177 µmol/l.
Diagnosis of arterial hypertension
When performing clinical and instrumental laboratory examinations in patients with arterial hypertension, the main goal should not be to establish the fact that blood pressure is elevated, but to discover the causes of the development of secondary arterial hypertension, signs of damage to internal organs, and to assess the presence of risk factors for the development of cardiac complications.
During the initial contact with the patient, the key to establishing a correct diagnosis and determining further treatment strategies is the careful collection of patient history data.In some cases, objective examination of patients with arterial hypertension can determine the pathogenesis of the disease by detecting specific pathological signs.Therefore, due to the presence of abdominal obesity in the patient, together with hirsutism, hirsutism, and a persistently elevated diastolic component, the disease should be assumed to be of an endocrine nature (itsenko-Cushing syndrome).In pheochromocytoma, accompanied by severe paroxysmal arterial hypertension, increased skin pigmentation is observed in the axillary protrusions.The main clinical diagnostic criterion for renovascular arterial hypertension is considered to be auscultation of vascular murmurs in the periumbilical region.
The range of laboratory investigation methods for arterial hypertension includes analysis of the patient's lipid profile, determination of uric acid and creatinine as the main criteria for renal insufficiency, and analysis of the patient's hormonal status.
In order to determine the stage of the disease, a necessary condition is the diagnosis of target organ damage, that is, organs that undergo irreversible changes due to increased blood pressure.Therefore, in order to detect dysfunction and organic damage of the heart, electrocardiographic recordings and ultrasound imaging are required as part of the standard screening examination of all patients with arterial hypertension.In order to detect retinopathy (mainly associated with long-term severe arterial hypertension), it is necessary to examine the patient's fundus.As an instrumental method 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 contribute to the early establishment of a correct diagnosis (computed tomography, magnetic resonance imaging).
Treatment of arterial hypertension
The basic modern approach to treating arterial hypertension is to minimize the risk of cardiac complications and mortality.In this regard, the primary task of the attending physician is the complete elimination of the reversible (modifiable) risk factors present in the patient and further pharmacological relief of arterial hypertension and the accompanying clinical manifestations.There are certain criteria, including reaching target blood pressure limits, which should not exceed 140/90 mmHg.
Under what circumstances should antihypertensive treatment be used for arterial hypertension?Cardiologists use a developed classification in practice, which involves assessing a patient's "risk of developing cardiovascular complications."Under this classification, people who are at high risk for heart complications and have severely elevated blood pressure need to receive a combination of lifestyle changes and medication corrections.Moderate and low-risk patients need dynamic observation for at least 3 months. Drug antihypertensive treatment should be taken only after non-drug correction is ineffective.
The principle of pharmacological correction of arterial hypertension involves the gradual lowering of blood pressure to target values through the use of minimal therapeutic doses of one or more antihypertensive drugs.In some cases, monotherapy with low-dose antihypertensive drugs may have a long-term positive effect in relieving arterial hypertension.Currently, the drug market is flooded with a variety of antihypertensive drugs, but the most popular are drug combinations with long-term antihypertensive effects (up to 24 hours).
As the drug of choice for the first episode of arterial hypertension, priority should be given to diuretics, which have a wide range of positive effects, prevent the occurrence of cardiovascular complications, reduce mortality, and prevent the progression of hypertrophic changes in the left ventricular myocardium.The pharmacological effects are accompanied by a mild decrease in blood pressure, resulting from a decrease in water and sodium reabsorption and a decrease in vascular resistance.
The choice of diuretic drug depends on the patient's existing comorbidities.Therefore, loop diuretic drugs should be given priority if arterial hypertension is complicated by signs of heart failure and renal failure.Long-term use of thiazide diuretics can cause hypokalemia syndrome, so it is best to use them in combination with an aldosterone antagonist.
A group of B-blockers are recommended as first-line agents when patients present with symptoms of arterial hypertension accompanied by symptoms of tachyarrhythmia, angina, and congestive chronic cardiovascular failure.The mechanism of action of these drugs is to reduce cardiac output and inhibit renin production.It should be taken into account that non-compliance with drug dosage in this group may cause a significant decrease in heart rate and bronchoconstriction, which is an absolute indication for discontinuation of B-blockers.
For patients with arterial hypertension due to proteinuria, it is recommended to take ACE inhibitor antihypertensive drugs.An absolute contraindication to the use of drugs from the ACE inhibitor group is existing bilateral renal stenosis in the patient.Drugs in the angiotensin II receptor antagonist group have similar blood pressure-lowering effects, the only difference being that they do not cause cough and angioedema, which significantly expands the scope of their use.
Calcium channel blockers have significant blood pressure-lowering effects and can relieve arterial hypertension by reducing the calcium content in the blood vessel walls.This category of prescribed drugs mainly includes elderly patients who also suffer from arterial hypertension and show signs of ischemic myocardial damage, manifesting as angina pectoris attacks.In cardiology 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 the case of patients with arterial hypertension combined with a disorder of the rhythm of cardiac activity, the use of calcium antagonists of the class of phenylalkylamines and benzodiazepine derivatives is recommended.An absolute contraindication to the use of this class of drugs is in patients with existing heart failure and a reduced ejection fraction below 45%.
Additionally, we should consider pharmacological relief of hypertensive crises, in which there is a sharp increase in intravascular pressure and an acute course of arterial hypertension.In this case, priority should be given to drugs with significant antihypertensive effects, because the risk of death increases sharply with the prolongation of the course of hypertensive crisis.If the patient has signs of a complicated hypertensive crisis, it is best to use the parenteral route of administration of drugs with antihypertensive effects.Most antihypertensive drugs are available in parenteral forms.Typically, the antihypertensive effect occurs within 5 minutes of administration.
In the case of uncomplicated hypertensive crisis, there is no need to use parenteral forms of antihypertensive drugs, since in this pathological condition there is no serious increase in blood pressure.Taking an adequate dose of oral antihypertensive medication can lower your blood pressure within a few hours and maintain your target level in the future.Of course, there are currently many pharmaceutical methods to alleviate hypertensive crisis, but in order to avoid complications, planned antihypertensive treatment programs should be adopted regularly.
If the patient's arterial hypertension is secondary and due to renal artery stenosis, the basic treatment is correction of the stenosis and revascularization with angioplasty.Surgical procedures for renovascular 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 hypertensive course caused by severe unilateral nephrosclerosis, the only treatment is nephrectomy.
For endocrine secondary arterial hypertension, surgical treatment (radical resection of the tumor stroma) is combined with pharmacological antihypertensive treatment (spironolactone, 200 mg daily for primary aldosteronism, phentolamine, 25 mg every 4 hours for pheochromocytoma).
Prevent arterial hypertension
The purpose of adhering to preventive measures is to prevent an increase in intravascular blood pressure and to reduce the risk of complications of arterial hypertension, not only in patients who have long suffered from this disease, but also in healthy individuals who may develop symptoms of hypertension.
It is scientifically proven that increased blood pressure is directly related to weight gain, therefore normalizing weight in patients with arterial hypertension is the main priority preventive measure.In addition, compliance with the rules of correcting dietary 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 demonstrated the beneficial effect of Omega-3-polyunsaturated fatty acids in restoring vascular tone, which can also be considered an effective method of preventing arterial hypertension.In light of these findings, you should consume adequate amounts of olive oil every day and strictly limit your intake of animal fats.
Of course, if you want to get rid of the manifestations of arterial hypertension, you should quit bad habits such as smoking and drinking, since nicotine and alcohol particles, even in microdoses, increase intravascular blood pressure.
For people who have already developed hypertension, as a secondary preventive measure, blood pressure should be measured every day, and the effectiveness of the drug treatment used should be recorded specifically. If the condition worsens and new clinical manifestations appear, please report it to the attending physician immediately.
Arterial Hypertension – Which Doctor Will Help?If you have or suspect you have arterial hypertension, you should seek immediate advice from a doctor such as a cardiologist, endocrinologist, and nephrologist.