Persistent hypertension. Arterial hypertension syndrome: symptoms and treatment of the disease. Drug therapy for arterial hypertension

Diseases of the cardiovascular system are widespread. This is due to both the increased frequency of their detection due to modern methods diagnostics, and with significant exposure to adverse environmental factors. One of the most common illnesses is arterial hypertension syndrome. It represents an increase in pressure in big circle blood circulation to 140/90 mm Hg. Art. and higher.

The occurrence of a problem is influenced by both the internal state of the body, for example, the functions of the endocrine or nervous system, and the effects of stress, poor nutrition and severe physical activity. At the same time, it is important to distinguish physiological increase blood pressure (BP) and cases when this state requires treatment. Elderly people with overweight bodies, however modern world The disease is increasingly common among young people. If primary hypertension is detected, symptomatic treatment is carried out. If the disease is secondary, therapy is aimed directly at the cause of the problem.

Types and degrees of arterial hypertension

This hemodynamic disorder is usually classified according to the severity of symptoms. This makes it easier to predict the disease, and is also crucial in determining tactics further treatment. There are 3 degrees of severity of hypertension syndrome:

Blood pressure readings are in the range of 140–150/90–100 mmHg. Art. This is considered a significant increase, but at this stage the disorder is easier to correct, since there is no damage to susceptible organs: kidneys, heart and brain.
The second degree of hypertension is characterized by greater severity of symptoms. The clinical picture is due to blood pressure levels reaching 160–170/100–110 mm Hg. Art. However, in many cases patients require hospitalization. At this stage, not only symptomatic therapy is required, but also drug support functions of target organs.
The third degree is the most severe manifestation of hypertension. The pressure in the vessels reaches 180/100 mm Hg. Art. and higher. Often it is not possible to correct this condition with medication due to the fact that the portal system, as well as the vessels of the kidneys and brain, are affected. The development of complications often leads to disability or even death of the patient.

It is customary to distinguish hypertension syndrome by etiology.

Primary

In such cases, hypertension develops independently. This means that the increase in pressure occurs without the influence of concomitant ailments. This etiology is detected in 80% of cases and is associated with cardiac dysfunction, as well as diseases of the vascular bed. It is generally accepted that essential hypertension is based on a hereditary predisposition. Of great importance in its development is also external environment, and in particular, the influence of stress. This is due to the peculiarities of the influence of the nervous system on vascular structures.

Secondary arterial hypertension

In some cases, the disease develops against the background of chronic diseases. These include kidney damage, endocrinopathies and central nervous system pathologies. Then arterial hypertension is secondary and symptomatic. It can also be iatrogenic, that is, caused by taking medicines. In such cases, therapy is aimed at the source of the hemodynamic disorder, since when the functioning of the internal organs is normalized, the pressure also stabilizes.

Causes

There are both external and endogenous factors that can provoke the formation of signs of arterial hypertension. The main ones include:

Age-related changes. Patients over 55 years of age are at high risk of developing the disease. This is due to metabolic transformations, as well as wear and tear of blood vessels.
Kidney damage is a common cause of hypertension. This is due to the active participation of these organs in controlling blood pressure levels.
A sedentary lifestyle negatively affects the health of the heart and blood vessels. They lose tone and are unable to maintain normal hemodynamics.
A history of endocrinopathies, such as diabetes mellitus or hyperthyroidism. The endocrine glands are capable of exerting both positive and negative influence on metabolism, leading to increased risk development of the disease.

Characteristic symptoms

Arterial hypertension syndrome is characterized by variability of manifestations. They depend on the severity of hemodynamic disorders, as well as on the causes of the disease in question. Long time the disease may not manifest itself in any way. However, when the body is no longer able to compensate for pathological processes, following symptoms arterial hypertension syndrome:

Significant fatigue and general weakness.
The appearance of dizziness and migraines is associated with the negative impact of increased pressure on the cerebral vessels.
Unpleasant sensations in the heart area. They occur periodically and can have varying intensity.
An increase in heart rate occurs in response to the development of hypertension. In some cases, tachycardia itself causes a surge in pressure.

The symptoms of hypertension are not specific and vary greatly from case to case. If such symptoms occur, you should consult a doctor.

Complications and consequences

A sustained increase in blood pressure is accompanied by damage to target organs, which primarily include the heart, brain and kidneys. With hypertension, their functions are impaired, which only aggravates the course of the disease. Frequent complications of grades 2 and 3 of hypertension syndrome are strokes and heart attacks, which are extremely difficult to combat. Another common consequence of a persistent increase in blood pressure is kidney failure, first acute and then chronic.

Diagnosis and treatment

Confirmation of the disease is based on periodic blood pressure measurements. It is carried out both at home and at a doctor’s appointment. In addition to tonometry, other methods are used to assess the degree of involvement of target organs in the pathological process. For this purpose, a survey ultrasound is performed. abdominal cavity, ECHO of the heart, ECG, and in some cases MRI or CT. Hematological tests are used to confirm endocrine disorders, as well as to identify lipid metabolism disorders.

When treating arterial hypertension syndrome, they often resort to medicinal methods. However, they are not the only option. Changing the patient’s lifestyle, especially his diet, is also of great importance. Traditional recipes are also used to combat unpleasant symptoms.

Drugs

Medicines that help lower blood pressure include:

Diuretics are medications that help remove fluid from the body. They help fight swelling and reduce stress on the heart. Representatives of the group are “Torasemide” and “Veroshpiron”.
Beta-blockers selectively act on nerve receptors, which is accompanied by relaxation of the vascular walls and a decrease in heart rate. These drugs include Bisoprolol and Atenolol.
Calcium antagonists have a pronounced effect on heart function. Most effective in cases of cardiogenic origin of arterial hypertension. The drugs in this group include Amlodipine and Verapamil.
ACE inhibitors are widely used due to their pronounced medicinal effect. They affect kidney function, preventing the cascade of reactions that initiate an increase in blood pressure. The most popular drugs are Enalapril and Monopril.

There is a study that showed possible use means for reducing blood pressure in endocrinology, and in particular in the treatment of type 1 diabetes mellitus. This disease is accompanied by the inability of pancreatic cells to produce insulin. Often this is a congenital problem that first appears in childhood. Scientists have found that important role The DQ8 molecule plays a role in pathogenesis. A drug used in the treatment of arterial hypertension, Methyldopa, which belongs to the group of adrenergic agonists, has a blocking effect on it.

The medication helps to significantly reduce the risk of developing symptoms of type 1 diabetes. At the same time, the product does not have a negative effect on immune system, in contrast to substances that were used for the same purpose. Further research into antihypertensive drugs may also contribute to treatment rheumatoid diseases, celiac disease and systemic lupus erythematosus. The use of Methyldopa not only in the treatment of arterial hypertension syndrome, but also in the fight against other pathologies is currently being studied, but researchers are already talking about high probability its successful use. This drug is considered the most effective substance in preventing the development of type 1 diabetes.

The following recipes are effective:

Flax seeds have positive influence on lipid metabolism. You only need three tablespoons of grains per day. They can be added to salads and side dishes.
Garlic infusion thins the blood and promotes dissolution cholesterol plaques. You will need to chop 2 cloves of the plant finely and pour a glass of boiling water. The mixture is infused for 12 hours. The finished medicine is taken in the morning and evening.

Proper nutrition

In case of hypertension syndrome, fried and fatty foods are excluded from the diet. It is better to cook by steaming to minimize the use of oil. You should also avoid salty foods because sodium chloride retains water. Preference should be given to vegetables and fruits, as well as low-fat varieties meat and fish.

Prevention

Preventing the development of hypertension comes down to following the rules healthy image lives that include moderate physical activity and balanced diet, as well as refusal bad habits. Regular tonometry and timely consultation with a doctor help prevent the progression of the disease.

Arterial hypertension is a disease characterized by increased blood pressure(over 140/90 mm Hg), which was recorded more than once. The diagnosis of arterial hypertension is made provided that elevated blood pressure (BP) is recorded in the patient in at least three measurements taken against a background of a calm environment and in different times, provided that the patient did not take any medications that could increase or decrease it.

Arterial hypertension is a common chronic disease in adults associated with increased blood pressure

Arterial hypertension is diagnosed in approximately 30% of middle-aged and elderly people, but can also be observed in adolescents. The average incidence rate for men and women is almost the same. Among all forms of the disease, moderate and mild ones account for 80%.

Arterial hypertension is a serious medical and social problem, as it can lead to the development of dangerous complications (including myocardial infarction, stroke), which can cause permanent disability, as well as death.

A long-term or malignant course of arterial hypertension leads to significant damage to the arterioles of target organs (eyes, heart, kidneys, brain) and instability of their blood circulation.

Risk factors

The main role in the development of arterial hypertension belongs to disorders regulatory function the higher parts of the central nervous system, which control the functions of all internal organs and systems, including the cardiovascular. That is why arterial hypertension most often develops in people who are often overworked mentally and physically, exposed to strong nervous shocks. Risk factors for the development of arterial hypertension include: harmful conditions labor (noise, vibration, night shifts).

Other factors predisposing to the development of arterial hypertension:

Family history of arterial hypertension. The likelihood of developing the disease increases several times in people who have two or more blood relatives suffering from high blood pressure.
Lipid metabolism disorders both in the patient himself and in his closest relatives.
Diabetes mellitus in the patient or his parents.
Kidney diseases.
Abuse of table salt. Consumption over 5.0 g table salt per day is accompanied by fluid retention in the body and spasm of arterioles.

Patients with established arterial hypertension should be consulted by an ophthalmologist, with a mandatory fundus examination.

To assess target organ damage, perform:

Ultrasound of the abdominal organs;
computed tomography of the kidneys and adrenal glands;
aortography;
excretory urography;

Treatment of arterial hypertension

Therapy for arterial hypertension should be aimed not only at normalizing high blood pressure, but also at correcting existing disorders of the internal organs. The disease is chronic, and although complete recovery is impossible in most cases, properly selected treatment of arterial hypertension helps prevent further development of the pathological process, reduces the risk of hypertensive crises and severe complications.

following a diet with limited salt and high levels of magnesium and potassium;
cessation of drinking alcohol and smoking;
normalization of body weight;
increasing the level of physical activity (walking, physical therapy, swimming).

Drug treatment of arterial hypertension is prescribed by a cardiologist; it requires a long time and periodic correction. In addition to the treatment regimen antihypertensive drugs according to indications, diuretics, antiplatelet agents, β-blockers, hypoglycemic and lipid-lowering agents are included, sedatives or tranquilizers.

The main indicators of the effectiveness of the treatment of arterial hypertension are:

reducing blood pressure to a level well tolerated by the patient;
no progression of target organ damage;
prevention of the development of complications from the cardiovascular system that can significantly worsen the patient’s quality of life or cause death.

Possible consequences and complications

A long-term or malignant course of arterial hypertension leads to significant damage to the arterioles of target organs (eyes, heart, kidneys, brain) and instability of their blood circulation. As a result, a persistent increase in blood pressure provokes the occurrence of myocardial infarction, cardiac asthma or pulmonary edema, ischemic or hemorrhagic stroke, retinal detachment, dissecting aortic aneurysm, and chronic renal failure.

According to statistics, in approximately 60% of women the disease occurs with the onset of menopause.

Arterial hypertension, especially severe, is often complicated by the development of a hypertensive crisis (episodes of a sudden sharp increase in blood pressure). The development of a crisis is provoked by mental overstrain, changes in meteorological conditions, and physical fatigue. Clinically hypertensive crisis manifests itself with the following symptoms:

significant increase in blood pressure;
dizziness;
intense headache;
increased heart rate;
feeling of heat;
nausea, vomiting, which may be repeated;
visual disturbances (flickering “fly spots” before the eyes, loss of visual fields, darkening of the eyes, etc.);

Against the background of a hypertensive crisis, disturbances of consciousness occur. Patients may be disoriented in time and space, frightened, agitated, or, conversely, inhibited. In severe cases of the crisis, consciousness may be absent.

A hypertensive crisis can lead to acute left ventricular failure, acute disorder cerebral circulation(ischemic or hemorrhagic stroke), myocardial infarction.

Forecast

The prognosis for arterial hypertension is determined by the nature of the course (malignant or benign) and the stage of the disease. Factors that worsen the prognosis are:

rapid progression of signs of target organ damage;
III and IV stages of arterial hypertension;
severe damage to blood vessels.

An extremely unfavorable course of arterial hypertension is observed in young people. They have a high risk of stroke, myocardial infarction, heart failure, and sudden death.

At early start treatment of arterial hypertension and provided that the patient carefully follows all the recommendations of the attending physician, it is possible to slow down the progression of the disease, improve the quality of life of patients, and sometimes achieve long-term remission.

Prevention of arterial hypertension

Primary prevention of arterial hypertension is aimed at preventing the development of the disease and includes the following measures:

giving up bad habits (smoking, drinking alcohol);
psychological relief;
proper balanced nutrition with limited fat and salt;
regular moderate physical activity;
long walks in the fresh air;
avoiding the abuse of caffeine-rich drinks (coffee, cola, tea, tonics).

When arterial hypertension has already developed, prevention is aimed at slowing the progression of the disease and preventing the development of complications. This type of prevention is called secondary prevention, and it includes the patient’s compliance with the doctor’s instructions regarding both drug therapy and lifestyle modification, as well as regular monitoring of blood pressure levels.

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Symptomatic arterial hypertension- such forms of increased blood pressure that are causally associated with diseases and damage to organs involved in the regulation of blood pressure.

Signs of symptomatic hypertension:

1) young age of patients;

2) in clinical picture AH syndrome is not the only one;

3) there are no or moderate lesions of target organs;

4) there is no hereditary burden;

5) crisis states are not very common;

6) formation of the syndrome of malignant arterial hypertension.

Classification of symptomatic arterial hypertension.

Vasorenal arterial hypertension
Renoparenchymal arterial hypertension
Endocrine arterial hypertension: pheochromacytoma, hyperaldosteronism, Itsenko-Cushing's disease and syndrome, thyrotoxicosis and hypothyroidism, hyperparathyroidism, acromegaly.
Hemodynamic arterial hypertension: coarctation of the aorta, aortoarteritis, aortic valve insufficiency.
Neurogenic arterial hypertension
Iatrogenic arterial hypertension

Vasorenal arterial hypertension

Various pathologies can lead to the development of RVH:

Atherosclerotic stenosis renal arteries (67% of RVH cases). It is usually found in men over 40 years of age and is more often unilateral. In most cases, stenosis is localized at the mouth and in the middle part of the renal arteries. One should think about RVH as a result of the development of atherosclerosis of the renal arteries when the transformation of mild hypertension into malignant hypertension occurs. In this case, atherosclerosis usually develops in other arteries (coronary, cerebral, etc.).
Fibromuscular dysplasia of the renal arteries - the second most common cause of RVH (10-20%).

Diagnostic keys And fibromuscularOuchdysplasiaAndrenal arteries:

* persistent, often malignant hypertension in young people (under 20 years old);

* characteristic systolic murmur in the projection of the renal artery;

* detection on the angiogram of the renal arteries of multiple narrowings alternating with poststenotic dilations (“strings of beads” or “rosaries”).

Thromboembolism of the main trunk or segmental branches along renal arteries occurs in 10% of patients with RVH.

Diagnostic keys thromboembolism of the renal arteries:

* intense pain in lumbar region, fever;

* macrohematuria;

* after these symptoms, hypertension appears;

* during ultrasound examination - kidney infarction;

* angiogram is a symptom of “amputation” of the renal artery trunk.

Nonspecific aortoarteritis (in 30% of patients with RVH). This disease leads to stenosis of the aorta and main arteries, including the renal ones, and to ischemia of the affected organ. More often women under 40 years old suffer from it.

Subjective manifestations RVG have no characteristic features.

Criteria for diagnosing RVH:

* severe hypertension with diastolic blood pressure greater than 115 mm Hg. Art.;

* resistance to drug antihypertensive therapy;

* presence of vascular murmur over the renal arteries;

* asymmetry of kidney size and function;

* positive test with captopril (significant decrease in blood pressure).

Aortography makes it possible to determine the nature, location, extent of the lesion and the degree of development of collateral circulation. A more effective method in diagnosing renovascular hypertension is computed tomography.

Renoparenchymal arterial hypertension

Associated with kidney diseases, whether it be a disease of the renal parenchyma (glomerulonephritis, pyelonephritis, cystic kidney, etc.), intrarenal arteries (vasculitis, nephroangiosclerosis), death renal tissue(chronic renal failure as an outcome of any kidney disease) and even the absence of a kidney (renoprial hypertension). Kidney pathology is the most common cause of secondary hypertension. For ease of diagnosis, everything parenchymal diseases kidneys are divided into two large groups:

1) glomerular nephropathies;

2) tubular nephropathies.

To glomerular nephropathies include: chronic diffuse glomerulonephritis, subacute glomerulonephritis, nephritis in diffuse diseases connective tissue, diabetic nephropathy, etc.

Criteria for the diagnosis of glomerular nephropathy:

* proteinuria more than 1 g/l;

* presence of hyaline casts in urine;

* normal urine density;

* hematuria;

* indications of symmetrical kidney damage.

Tubular nephropathies include pyelonephritis and interstitial nephritis.

Criteria for the diagnosis of tubular nephropathy:

* proteinuria no more than 1 g/l;

* leukocyturia;

* bacteriuria;

* indication of asymmetry of kidney damage.

Glomerulonephritis (GLN) . Diagnostic keys:

* combination of hypertension with urinary syndrome and pain in the lumbar region, especially

but if there is a history of streptococcal infections (tonsillitis, scarlet fever);

* characteristic changes in urine tests;

* a history of acute GN or nephropathy in pregnancy;

* results of nephrobiopsy analysis.

Alport syndrome - hereditary non-immune glomerulopathy associated with pathology of collagen in the basement membranes of glomerular capillaries, manifested by hematuria and/or proteinuria, a progressive decrease in renal function, often combined with pathology of hearing and vision. Alport syndrome manifests clinically at the age of 3-5 years.

Diagnostic keys:

* micro- or macrohematuria (most common symptom, often provoked by acute respiratory infection);

* proteinuria (may be absent during the first years of the disease, intermittent nature of proteinuria is possible);

* abacterial leukocyturia (non-permanent symptom);

* hearing loss due to neuritis of the auditory nerve (hearing loss, hearing loss is more common in males, and sometimes earlier than changes appear in urine tests);

* decreased visual acuity (in 65-70%), changes in the lens and cornea (anterior and posterior lenticonus, keratoconus, congenital spherophakia, bilateral cataracts), myopia, nystagmus;

* microneurological symptoms (in 90% of patients).

Chronic pyelonephritis (CPn)

One should think about pyelonephritis as a cause of hypertension:

if a patient is 60-70 years old, systolic hypertension gradually turns into systolic-diastolic;
if there is a relationship between exacerbations of pyelonephritis and an increase in diastolic blood pressure;
if hypertension progresses along with renal failure.

Polycystic kidney disease – is a common pathology and accounts for 12-14% of all kidney diseases.

Diagnostic keys:

* there is no normal circadian rhythm of blood pressure;

* pain in the lumbar region;

* palpation of enlarged kidneys in the form of tumor-like formations;

* polyuria, nocturia, development of renal failure;

* Ultrasound and radiological signs polycystic disease.

Endocrine arterial hypertension: pheochromacytoma, hyperaldosteronism, Itsenko-Cushing's disease and syndrome, thyrotoxicosis and hypothyroidism, hyperparathyroidism, acromegaly.

Primary hyperaldosteronism (Conn's syndrome). The main manifestations of the disease are associated with hyperproduction of aldosterone by the zona glomerulosa of the adrenal cortex. Conn's syndrome occurs in 0.5% of cases of hypertension. A single benign tumor, in 10-15% - multiple adenomas. Malignant tumors of the adrenal cortex are extremely rare. The most important pathogenetic factor in the development of hypertension in this pathology is a violation of the intracellular ratios of Na + and K + content, suppression of renin secretion, which leads to activation of the pressor group of kidney prostaglandins. In the clinical picture of the disease, it is necessary to distinguish between symptoms caused by hypertension and symptoms caused by hypokalemia. Hypertension is accompanied by headaches, dizziness, etc. Hypokalemia is manifested by general weakness, aggravated in winter, transient paresis, tetany, which are relieved by intravenous administration of potassium chloride or panangin (medicinal diagnostic test). Signs of organic lesions of the central and peripheral nervous system are usually absent. Hypokalemia is reflected on the ECG. Conn's syndrome is characterized by renal syndrome: polydipsia, polyuria, nocturia, hyposthenuria (specific gravity of urine 1007-1015), alkaline urine reaction. Hypertension in this disease can have a labile and stable course, or a crisis course (in approximately 40% of patients).

At stage II of examination for Conn's syndrome:

- the content of aldosterone in the blood or urine is determined:

- the content of renin in the blood is determined;

- topical diagnosis of adrenal adenoma is carried out using ultrasound, computed tomography(CT).

Diagnostic keys:

* tetany, muscle weakness, worse in winter;

* paresthesia;

* renal syndrome: polyuria, nocturia, hyposthenuria, alkaline reaction

* hypertension syndrome;

* hypokalemia (ECG and biochemical);

* increased urinary excretion of aldosterone (normal 5-20 mcg/day);

* increasing the level of aldosterone in the blood;

* decreased plasma renin activity;

* absence of edema (with Conn's syndrome they do not occur).

Pheochromocytoma (chromaffinoma ) . Pheochromocytoma — This is a tumor that develops from chromaffin cells located in the adrenal medulla, sympathetic ganglia and paraganglia. In 90% of cases, pheochromocytoma is localized in the adrenal medulla, in 10% there is an extra-adrenal localization, then it can be localized along the thoracic and abdominal aorta, in the hilum of the kidneys, in the bladder. Tumors localized in the adrenal glands and in the wall of the bladder secrete adrenaline and norepinephrine, while tumors in other locations secrete only norepinephrine. Pheochromocytoma is found in 0.1% of patients with hypertension. At the core pathogenesis The disease is due to the effect on the body of catecholamines secreted by the tumor. It is, on the one hand, determined by the amount, ratio and rhythm of catecholamine secretion, and on the other, by the state of the α- and β-adrenergic receptors of the myocardium and vascular wall. Chromaffin cells belong to the APUD system, therefore, under conditions of tumor degeneration, they are capable, in addition to catecholamines, of secreting other amines and peptides, for example, serotonin, vasoactive intestinal peptide, and ACTH-like substance. This, apparently, explains the diversity of the clinical picture of the disease. Klee neither ical picture. In the vast majority of patients with pheochromocytoma, the clinical picture is characterized by crisis hypertension, and crises occur against the background of both normal and elevated blood pressure. During crises, blood pressure rises instantly, within a few seconds, reaching figures of 250-300/130-150 mm Hg. Art. The patient feels fear, the skin of the face is pale. Hearing and vision are often impaired, thirst and the urge to urinate occur. Body temperature rises, tachycardia occurs, leukocytosis and hyperglycemia are observed in the blood. The frequency of crises varies: from 1-2 times a month to 12-13 times a day, and, as a rule, increases with the duration of the disease. The usual duration of crises is from a few minutes to 30 minutes. The recovery from a crisis with pheochromocytoma does not occur in the same way as with hypertension. Due to the active destruction of circulating catecholamines, blood pressure decreases rapidly, often with postural hypotension.

It is usually customary to distinguish three clinical variants of the course of pheochromocytoma accompanied by hypertension:

1) paroxysmal (crisis) variant;

2) option of stable crisis-free hypertension;

3) the option of combining stable hypertension with crises.

We must remember the existence of an asymptomatic, latent clinical form of pheochromocytoma, when blood pressure rises very rarely. The patient may die from the first crisis, since by this time there is no LVH, so the patient may develop acute left ventricular failure. Chronic hypercatecholaminemia and hypertension in patients with pheochromocytoma lead to significant changes in the myocardium, which manifests itself in ECG sinus tachycardia, rhythm disturbances (ventricular and supraventricular extrasystoles, pacemaker migration), decreased ST segment, decreased or negative T wave. Sometimes these changes on the ECG are so similar to the ECG picture of myocardial infarction that they are extremely difficult to differentiate. In some cases, pheochromocytoma occurs with abdominal syndrome. The clinical picture resembles " acute stomach"and includes abdominal pain without clear localization, not associated with food intake, nausea and vomiting. All this manifests itself against the background of hypertensive crises with pallor and sweating.

Diagnostic keys:

* crises with a pronounced sympathoadrenal coloring;

* “ischemic” changes on the ECG;

* combination of high blood pressure with tachycardia and weight loss;

* increased content of catecholamines in daily urine;

* increasing the content of vanilla-mandelic acid in daily urine;

* detection of a tumor in the adrenal gland area using ultrasound and CT.

Hypercorticism. This syndrome is observed:

— with pituitary-hypothalamic lesions, in particular with ACTH-producing pituitary adenoma (about 80%) of cases);

- with lesions of the adrenal glands, more often with adenomas of the zona fasciculata of the adrenal cortex (about 20% of cases) - Itsenko-Cushing syndrome;

- when taking glucocorticosteroids - exogenously caused hypercortisolism. Pathogenesis Hypertension with hypercortisolism: hyperproduction of adrenal hormones, primarily cortisol, but sometimes the production of aldosterone can also increase.

Clinical picture Itsenko-Cushing syndrome is very typical. The following are distinguished clinical syndromes:

— asthenoadynamic (in 95% of patients): general weakness, fatigue, decreased performance, mental disorders up to a depressive state;

— hypertensive (in 91% of patients);

— osteoporotic (in 88% of patients);

— dysplastic obesity (in 93% of patients);

— sexual dysfunction (in 72% of patients): manifested in women by menstrual irregularities, amenorrhea, infertility, hirsutism and lactorrhea; in men – impotence and sterility;

- carbohydrate metabolism disorders up to steroid diabetes (in 35% of patients).

Stage II studies:

— determination of the excretion of 17-KS and 17-OX in daily urine and the content of 11-OX in the blood;

— determination of the basal level of ACTH and cortisol in the blood;

- glycemic profile;

- radiography, tomography and CT of the sella turcica.

For differential diagnosis between an adrenal adenoma (glucocorticosteroma) and a pituitary adenoma (Itsenko-Cushing's disease), the following studies must be carried out:

— Ultrasound of the adrenal glands;

— scintigraphy of the adrenal glands with 1311-cholesterol;

- computed tomography;

- dexamethasone test. First, a so-called small dexamethasone test is performed. There are several options:

When using cortisol levels in the blood as a hormonal criterion, a single dose of 1 mg of dexamethasone is used. The level of cortisol in the blood is assessed at 8 hours after preliminary administration of dexamethasone (1 mg) at 23-24 hours, as well as the difference in basal levels of the hormone before and after the test. If the content of 17-KS and 17-OX in daily urine is used as a criterion for diagnosing hypercortisolism, a test option using 0.5 mg of dexamethasone every 6 hours for 2 days is recommended. In the absence of Itsenko-Cushing syndrome, daily secretion of 17-OX after taking dexamethasone decreases to 11 µmol/l and below. If the test is positive in favor of Itsenko-Cushing syndrome, a large dexamethasone test is used. To differentiate Cushing's disease and glucocorticosteroma, 2 mg of dexamethasone is prescribed every 6 hours for 2 days. The test is considered positive when the content of 17-OX in the urine decreases by 40-45%. Itsenko-Cushing's disease is characterized by a positive test, for tumors of the adrenal cortex (most tumors have autonomous cortisol secretion and do not respond to dexamethasone) - negative.

Diagnostic keys:

* hirsutism;

* dysplastic obesity;

* general weakness;

* moon-shaped face, the appearance of stretch marks on the skin of the lateral surfaces of the body;

* osteoporosis;

* increased excretion of 17-KS and 17-OX in daily urine;

* detection of a tumor in the area of the adrenal glands (with an adenoma from the zona fasciculata of the adrenal glands) during ultrasound and computed tomography;

* detection of adenoma (or microadenoma) of the pituitary gland by radiography of the sella turcica, and, if necessary, by CT scan.

Hemodynamic arterial hypertension

Hypertension caused by disturbances in systemic hemodynamics develops in a number of diseases (Table 8), the diagnosis of which usually does not cause significant difficulties: the clinical picture of these diseases clearly shows the manifestations of the main pathological process; hypertension, more often systolic, usually does not dominate.

Atherosclerotic hypertension. Hypertension is caused by age-related sclerotic changes (collagenization) of the medial tunic of the aorta and a decrease in its elasticity, due to which it damps the pulse pressure drop worse, and the resistance to cardiac output increases. A characteristic feature of atherosclerotic hypertension is a chronic, although unstable, increase in SBP above 160-170 mmHg. with normal or low diastolic pressure.

Table 8. Main forms of hemodynamic hypertension

Diagnostic keys:

* elderly and senile age;

* predominant increase in systolic blood pressure

* blood pressure numbers are often labile, systolic hypertensive crises are possible; In 1/2 of the patients, hypertension is asymptomatic, in others it is accompanied by cerebral complaints;

* determined by fast and high heart rate, sometimes Quincke’s capillary pulse, “carotid dance” (in the absence of aortic insufficiency);

* availability of direct and indirect signs atherosclerosis of the aorta (radiography of the heart, echocardiography), coronary arteries (clinical and ECG signs of ischemic heart disease, echocardiographic signs of ischemic heart disease), cerebral vessels, vessels of the lower extremities, intermittent claudication syndrome, Doppler ultrasound examination of blood vessels).

Coarctation of the aorta — one of the most common vascular anomalies, occurs in 4.0-8.5% of cases of all congenital diseases of the heart and its large vessels. When characterizing coarctation of the aorta, its length and localization in relation to the large arteries extending from the aortic arch and to the ductus arteriosus are taken into account. In addition, it is taken into account whether this duct is closed. A.V. Pokrovsky (1979) distinguishes three types of coarctation of the aorta:

Type I – isolated coarctation of the aorta – at the point of transition of the aortic arch into its descending section (in 79% of cases out of 506 observations);

Type II – a combination of coarctation of the aorta with open ductus arteriosus(in 3.8% of patients over 5 years old);

Type III – a combination of coarctation of the aorta with others birth defects hearts.

Hypertension during coarctation of the aorta is formed under the influence of several factors: 1) mechanical obstruction to blood flow and a decrease in the capacity of the elastic chamber of the aorta; 2) development of renal ischemia with activation of the RAAS.

Narrowing thoracic The aorta creates different circulatory conditions for the upper and lower halves of the body, which gives a unique clinical picture of the disease. Patients experience pain, which, on the one hand, is associated with hypertension, hypervolemia and hypercirculation in the upper half of the body, and on the other hand, with hypotension, hypovolemia and hypocirculation in the lower half of the body. The complaints of patients can be divided into two groups: the first group includes complaints of heaviness and pain in the head, dizziness, tinnitus, nosebleeds, shortness of breath, chest pain and diffuse pain in the chest caused by the pressure of vascular collaterals on the ribs, and the second group - complaints of weakness and pain in the legs, cramps in the leg muscles, coldness of the feet. Sometimes this symptomatology resembles intermittent claudication syndrome. Objective signs of coarctation of the aorta are very characteristic. With good enough physical development in adults there is plethora of the face and neck, sometimes hypertrophy shoulder girdle; the lower extremities may be hypotrophic, pale and cold to the touch. The arterial vessels of the neck pulsate intensely; in the lateral parts of the chest, pulsation of subcutaneous vascular collaterals is visible. The pulse in the radial arteries is tense and high, and the pulse in the arteries of the lower extremities is low in volume and tension. Blood pressure in the arms is increased and in the legs it is low. Another important sign of aortic coarctation is a systolic murmur with transition to diastole, heard in the 2nd-3rd intercostal spaces on the left at the sternum and behind in the left interscapular space (sometimes the murmur is heard only here). The ECG shows signs of hypertrophy and systolic overload of the left ventricle. An X-ray examination reveals pronounced pulsation of the aorta to the site of its narrowing, post-stenotic dilatation of the aorta, aortic configuration of the heart and usuration of the lower edges of the IV-VIII ribs. All or part of the above signs allow us to suspect coarctation of the aorta, and then, using invasive methods, clarify its nature and the need for surgical intervention. For this purpose, aortography and probing of the heart cavities are performed. Using aortography, the location of the narrowing of the aorta and the length of the narrowing, the presence of an aortic aneurysm and intercostal aneurysms are determined.

Diagnostic keys :

* vertical dyscirculation syndrome;

* systolic murmur with transition to diastole;

* collateral blood flow syndrome.

Aortic valve insufficiency. Systolic hypertension is characteristic due to an increase in left ventricular end-diastolic volume and stroke volume. DBP usually decreases, pulse blood pressure increases.

Diagnostic keys :

* pulsation of neck vessels, head shaking;

* resistive rising cardiac impulse, shifted to the left and

* aortic configuration of the heart;

* soft protodiastolic murmur in the second intercostal space on the right;

* presystolic Flint murmur;

* fast high pulse;

* instrumental methods visualization of the defect: EchoCS, FCG, X-ray methods, cardiac catheterization.

A G caused by an increase in circulating blood volume (rheological). Iatrogenic (excessive intravenous fluid administration), polycythemia vera. Increased blood pressure in polycythemia is called Heisbeck syndrome. Plethoric syndrome, thrombosis, increased red blood cells, hemoglobin, hematocrit, leukocytes, platelets. Verification of the diagnosis using sternal puncture (three-line bone marrow hyperplasia).

A G with complete atrioventricular block associated with increased cardiac output. Complete atrioventricular block is characterized by bradycardia, and Strazhesko’s “gun tone” can be heard; The diagnosis is confirmed by an ECG study.

Neurogenic arterial hypertension

This group of symptomatic hypertension consists of such forms of acute or chronic increase in blood pressure that are associated with diseases of the brain and spinal cord. At various states, accompanied by an increase in intracerebral pressure (tumors, brain injuries, thalamic cysts, etc.), hypertension is often observed. They are often grouped together under the name "Penfield syndrome." In addition to a paroxysmal increase in blood pressure, this syndrome is characterized by severe headaches, severe dizziness, sweating, tachycardia, salivation, cutaneous vasomotor and pilomotor reactions, abdominal pain, seizures, nystagmus, and often terminal polyuria. An increased secretion of catecholamines is detected in the urine.

Diseases of the spinal cord and peripheral nervous system (infectious, toxic polyneuritis, polyradiculitis) can also cause hypertension, usually of the paroxysmal type.

Diagnostic keys:

* lack of hereditary predisposition to hypertension;

* detection of signs of increased intracranial pressure in the patient

(bradycardia, edema and congestion in the area of the optic nerve nipple);

* presence of autonomic dysfunction simultaneously with hypertension;

* availability of organic neurological symptoms;

* progressive personality change;

* detection of changes on a computer tomogram.

Iatrogenic arterial hypertension.

The prevalence of hypertension developing during various surgical interventions ranges from 30 to 80%. This range of indicators is apparently associated with different interpretations of hypertension levels by different researchers. Hypertension that develops during surgical treatment causes hemorrhagic complications, such as cerebral hemorrhage or bleeding along the suture. Mortality caused by these complications of hypertension reaches 50% in operated patients. The hemodynamic basis for the increase in blood pressure in such patients is a sharp increase in total peripheral resistance associated with an increase in the level of catecholamines in the circulating blood; hypertension in the postoperative period requires immediate drug treatment.

Treatment of GAS

Five main classes of antihypertensive drugs are currently recommended for drug therapy of hypertension:

angiotensin-converting enzyme inhibitors (ACEIs),
angiotensin receptor blockers (ARBs),
calcium antagonists (CA),
beta blockers (BAB)
diuretics.

Angiotensin-converting enzyme inhibitors

Preferred indications for CHF, left ventricular dysfunction, ischemic heart disease, LVH, atrial fibrillation, diabetes mellitus, metabolic syndrome, carotid atherosclerosis, nephropathy, proteinuria, microalbuminuria

Contraindications Pregnancy, hyperkalemia, bilateral renal artery stenosis, angioedema

Captopril 50–100 mg in 2–3 doses

Enalapril 10–20 mg in 1–2 doses

Perindopril 4–6 mg per dose

Lisinopril 10–40 mg per dose

Fosinopril 10–40 mg in 1–2 doses

Angiotensin receptor blockers

Preferred indications for CHF, previous myocardial infarction, LVH, atrial fibrillation, diabetes mellitus, metabolic syndrome, diabetic nephropathy, proteinuria, microalbuminuria, cough when taking ACE inhibitors

Contraindications Pregnancy, hyperkalemia, bilateral renal artery stenosis

Drugs, daily doses and frequency of administration

Losartan 50–100 mg per dose

Valsartan 80–160 mg per dose

Candesartan 8–16 mg per dose

Eprosartan 600 mg per dose

Dihydropyridine calcium antagonists

Preferred indications for ISAH, hypertension in the elderly, ischemic heart disease, LVH, atherosclerosis of the carotid and coronary arteries, pregnancy

Relative contraindications Tachyarrhythmias, CHF

Drugs, daily doses and frequency of administration

Nifedipine retard 30–60 mg per dose

Nicardipine retard 60–120 mg in 2 doses

Isradipine retard 5–10 mg per dose

Felodipine retard 5–10 mg per dose

Amlodipine 5–10 mg per dose

Non-dihydropyridine calcium antagonists

Preferred indications: IHD, carotid atherosclerosis, supraventricular tachyarrhythmias

Absolute contraindications: Atrioventricular block 2–3 degrees, CHF

Drugs, daily doses and frequency of administration

Verapamil retard 240–480 mg in 1–2 doses

Diltiazem retard 180–360 mg in 2 doses

Beta blockers

Preferred indications: IHD, previous myocardial infarction, CHF, tachyarrhythmias, glaucoma, pregnancy

Absolute contraindications: Atrioventricular block 2–3 degrees, bronchial asthma

Relative contraindications Peripheral arterial disease, metabolic syndrome, impaired glucose tolerance, high physical activity, COPD

Drugs, daily doses and frequency of administration

Atenolol 25–100 mg in 1–2 doses

Acebutolol 200–800 in 1–2 doses Betaxolol 10–20 mg in 1 dose Bisoprolol 2.5–5 mg in 1 dose

Carvedilol 25–75 mg in 2 doses

Labetolol 200–800 mg in 2–3 doses Metoprolol 50–200 mg in 2–3 doses

Nadolol 40–160 mg per dose

Nebivolol 2.5–5 mg per dose

Oxprenolol 60–200 mg in 2–3 doses

Pindolol 10–40 mg in 2–3 doses

Propranolol 60–160 mg in 2–3 doses

Sotalol 80–160 mg in 1–2 doses

Celiprolol 200–500 mg in 1–2 doses

Thiazide diuretics

Preferred indications for ISAH, hypertension in the elderly, CHF

Absolute contraindications Gout

Relative contraindications Metabolic syndrome, impaired glucose tolerance, dyslipidemia, pregnancy

Drugs, daily doses and frequency of administration

Hydrochlorothiazide 12.5–50 mg per dose

Indapamide 1.25–2.5 mg per dose 28

Aldosterone antagonists

Preferred indications for CHF, previous myocardial infarction

Absolute contraindications Hyperkalemia, chronic renal failure

Drugs, daily doses and frequency of administration

Spironolactone 12.5–25 mg per dose

Loop diuretics

Preferred indications End stage chronic renal failure, heart failure

Drugs, daily doses and frequency of administration

Furosemide 20–600 mg in 1–2 doses

Bumetanide 0.5–10 mg in 1–2 doses

Torsemide 2.5–5 mg per dose

Ethacrynic acid 25–200 mg in 1–2 doses

Many people around the world suffer from a disease called hypertension. Other common names for the disease are hypertension, hypertension, essential hypertension. Unfortunately, this pathology is very often detected in pregnant women. With timely treatment, it is possible to improve the condition of patients and prevent serious complications.

Arterial hypertension (AH) - definition of increased systolic (more than 139 mm Hg) and/or diastolic (more than 89 mm Hg) for a long time. It can occur for no apparent reason or against the background of other diseases (kidney pathologies). Often develops after myocardial infarction or stroke.

“The boundary between normal and elevated blood pressure is determined by the level above which interventions have been shown to reduce the risk of adverse health effects.” WHO Expert Committee on the Control of Hypertension, 1999.

During the examination of patients with suspected hypertension, a number of studies are carried out (initial examination, instrumental and laboratory). The diagnosis is made based on sphygmomanometry. After confirmation of the diagnosis, antihypertensive therapy is prescribed, the absence of which leads to disability, and in the worst case, death.

Video Live great! Arterial hypertension 18 05 12

What is arterial hypertension?

Blood pressure level directly depends on cardiac output and total peripheral vascular resistance. To create a prerequisite for arterial hypertension, the following must be observed:

increased cardiac output (CO);
increased total peripheral vascular resistance (TPVR);
simultaneous increase in CO and OPSS.

In most cases, patients with hypertension experience an increase in OPSS and a slight increase in CO. Not so common, but still found, is another model of the development of hypertension: CO increases, while TPSS values remain at normal level or do not correspond to the change in SV. A persistent increase in only systolic pressure, which is accompanied by a reduced or normal CO, can also be determined. In other cases, diastolic pressure increases against the background of decreased CO.

The following pathological mechanisms may be involved in the development of arterial hypertension:

Violation of Na transport. Due to the complex metabolic processes and various microcirculatory disorders, the concentration of Na inside the cell can increase, which helps to increase sensitivity to stimulation by the sympathetic nervous system. As a result, myocardial cells begin to contract more often, and this leads to an increase in cardiac output and the development of hypertension.
Sympathicotonia. Provokes an increase in blood pressure. This is especially common in patients with prehypertension, when systolic blood pressure can reach 139 mm Hg, and diastolic blood pressure can reach 89 mm Hg. Art.
Renin-angiotensin-aldosterone system. Quite complex in its work, its main task is to regulate the volume of circulating blood due to water and Na retention, which in turn increases blood pressure. The key mechanisms for regulating this system are located in the kidneys, so hypertension can occur in diseases of these organs.
Lack of vasodilators. Substances such as nitric oxide and bradykinin promote vasodilation. When they are deficient in the blood, hypertension occurs. A similar disorder occurs in kidney disease, which produces vasodilators, and endothelial dysfunction, since endothelial cells also produce substances that dilate blood vessels.

Why is the problem of arterial hypertension so urgent?

After 65 years, two thirds of people suffer from hypertension.
After 55 years, even if normal blood pressure is determined, the risk of its increase is 90%.
The harmlessness of high blood pressure is imaginary, since this disease increases the risk of mortality against the background of the development of conditions such as coronary artery disease, myocardial infarction, and stroke.
Hypertension can rightfully be considered an expensive disease. For example, in Canada, hypertension accounts for up to 10% of the healthcare budget.

Some statistics:

In Ukraine, 25% of adults suffer from hypertension.
High blood pressure is detected in 44% of the adult population of Ukraine.
On average, 90% of patients with hypertension have a primary form of the disease.
In America, about 75 million people suffer from hypertension. Of this number, 81% are those who are aware of their disease, with more than 70% receiving treatment and just over 50% having adequate blood pressure control.

Classification

Since 1999, levels of increased blood pressure have been taken as the basis for the division of arterial hypertension. The data presented applies to patients over 18 years of age.

Classification of hypertension by blood pressure level (WHO, 1999), where SBP is systolic blood pressure, DBP is diastolic blood pressure:

The optimal level is SBP no more than 120 mmHg. Art., DBP - no more than 80 mm Hg. Art.
Normal level - SBP - no more than 130 mm Hg. Art., DBP - 85 mm Hg. Art.
High normal blood pressure - SBP - 130-139 mm Hg. Art., DBP - 85-89 mm Hg. Art.
First degree of hypertension (mild) - SBP - 140-159 mm Hg. Art., DBP - 90-99 mm Hg. Art.
The second degree of hypertension - SBP - 160-179 mm Hg. Art., DBP - 100-109 mm Hg. Art.
The third degree of hypertension - SBP - more than 180 mm Hg. Art., DBP - more than 110 mm Hg. Art.
Isolated systolic hypertension - SBP more than 140 mmHg. Art., DBP - not higher than 90 mm Hg. Art.

In 2003, the American National Joint Committee proposed a more simplified classification of hypertension:

Normal blood pressure is not higher than 120/80.
Prehypertension - SBP - 120-139 mm Hg. Art., DBP - 80-89 mm Hg. Art.
First degree hypertension - SBP - 140-159 mm Hg. Art., DBP - 90-99 mm Hg. Art.
Second degree hypertension - SBP - more than 160 mm Hg. Art., DBP - more than 100 mm Hg. Art.

At long term Arterial hypertension can affect various organs and systems. Based on this, a classification has been formed taking into account the affected target organs (WHO, 1993):

The first stage (III) - the organs are not affected.
Second stage (II) - symptoms of involvement of one or more organs in the process (left ventricle, retinal arteries, kidneys, large vessels) are determined.
Third stage (III) - the course of the disease is complicated clinically severe diseases heart, kidneys, brain, retina, blood vessels.

The diagnosis indicates the stage of arterial hypertension and the affected target organ. If, against the background of hypertension, a heart attack or angina occurs, which is confirmed by research, this is also indicated in the diagnosis.

Reasons

In almost 90% of cases, the exact cause of arterial hypertension cannot be determined. Then a disorder of the central nervous system is suspected, which can occur as a result of exposure to various predisposing factors (stress, increased body weight, physical inactivity, etc.).

In the remaining 10% of cases, hypertension develops against the background of other diseases, which are often associated with the kidneys, tumor processes, misuse medicines and so on.

Kidney diseases

Kidney pathology combined with arterial hypertension accounts for 4% of all cases of hypertension. Most often, hypertension develops when:

glomerulonephritis;
pyelonephritis;
polycystic kidney disease;
renal failure.

Sometimes defects in the renal artery, whether congenital or acquired, lead to narrowing of the vessel, which also causes hypertension.

Adrenal diseases

If the activity of this organ is disrupted, the production of mineralocorticoids, which affect the functioning of the kidneys, may change. In particular increased content Aldosterone leads to narrowing of small-caliber arteries and retention of salts by the kidneys. Such processes lead to increased blood pressure. Also, a benign tumor known as pheochromocytoma can form in the adrenal glands, which increases the synthesis of adrenaline and, as a result, leads to narrowing of the arteries. This causes hypertension.

Toxicosis in pregnant women

Due to hormonal and immunobiological changes in the body of a pregnant woman, later Blood pressure may increase. Such circumstances disrupt the process of gestation. In severe cases, premature delivery is performed, most often through cesarean section.

Video HYPERTENSION. High blood pressure - causes. How to remove it forever

Risk factors

There are modified and unmodified risk factors, that is, those that are extremely difficult to influence.

Unmodified:

Hereditary predisposition.
Age.
Race.

Modified:

Climatic conditions.
Poor nutrition.
Poor quality water.
Poor housing microclimate.
Increased body weight.
Reduced activity.
Frequent stress.
Bad habits.
Deficiency of microelements and vitamins.
Hormonal disorders.

With unfavorable heredity, a defect may be observed cell membranes, defect in the kinin system, pathological ability of smooth muscle cells to increase and change.

The race factor also plays an important role, since among adult African Americans hypertension is detected in 41% of cases, and among Europeans, as well as Mexican Americans, in 28% of cases.

Species

Based on their origin, hypertension is divided into primary and secondary. The primary form of arterial hypertension is also known as essential hypertension.

The concept of “essential hypertension” is recommended by WHO (1978) to define a condition in which there is high blood pressure without an obvious cause. It corresponds to the term “hypertension”, which is common in our country.

The concept of “secondary hypertension” was adopted by WHO (1978) to define hypertension, the cause of which can be identified. It corresponds to the term “symptomatic hypertension”, which is common in our country.

Primary hypertension

It is determined in patients in 90% of cases, since its development is associated with numerous factors, including heredity. To date, geneticists have been able to identify more than a dozen genes that are responsible for the development of hypertension. There are several forms of primary hypertension, which differ in the specific clinical features:

Hypo- and normorenine form. It is more often detected in the elderly and middle-aged people. Develops against the background of excessive retention of water and salts in the body due to the activity of renin and increased concentration aldosterone.
Hyperrenin form. Occurs in 20% of all cases of primary hypertension. It is more often detected in young male patients. It is quite difficult, since blood pressure can rise sharply and high. Before the development of this form of hypertension, periodic increases in blood pressure could be observed.
Hyperadrenergic form. Its occurrence is 15%. It is often detected in young people who have not previously complained of hypertension. It is characterized by an increased amount of norepinephrine and adrenaline in the blood. It often progresses into a hypertensive crisis, especially in the absence of adequate treatment.

Secondary hypertension

The second known definition of the disease - symptomatic hypertension - indicates its connection with diseases that may be complicated by high blood pressure. The following forms of secondary hypertension exist:

Cardiovascular. They develop against the background of diseases such as complete AV block, coarctation of the aorta, and heart defects.
Neurogenic. Occurs when brain structures are damaged due to vascular atherosclerosis, tumor process, encephalitis and encephalopathy.
Endocrine. Often associated with thyroid dysfunction, when there is increased or decreased production of thyroid hormones. Other disorders may also occur endocrine glands according to the type of pheochromocytoma, acromegaly, hypothalamic syndrome.
Renal. Develops against the backdrop of various kidney diseases in the form of renal failure, diabetic nephropathy, transplanted organ, etc.
Medicinal. Chronic use of certain medications leads to the development of secondary hypertension.
Blood diseases. Some pathologies are accompanied by an increase in the number of red blood cells in the blood, resulting in hypertension.

The course of the disease may also vary. In some cases it is slow, there are no sharp rises in blood pressure, then they talk about benign hypertension. Often it develops unnoticed by both the patient and the doctor, as a result of which it is detected at a late stage.

Malignant hypertension characterized by pronounced progression of all pathological processes. The patient’s well-being is getting worse every day, so the lack of appropriate treatment can lead to his death.

Clinic

Patients may respond differently to increased blood pressure. Some note pronounced signs, others do not notice the changed condition at all.

Symptoms characteristic of arterial hypertension:

Headaches that can be perceived as bursting, aching or pressing. They are most often localized in the back of the head and occur early in the morning.
The heartbeat quickens, and there may be interruptions in the functioning of the heart.
Autonomic disorders are manifested by tinnitus, dizziness, the appearance of spots before the eyes,
Astheno-neurotic syndrome is expressed in weakness, bad mood, sleep and memory disorders. Increased fatigue may also occur.

Depending on the course of the disease, hypertensive crises may be absent or detected. These pathological conditions extremely worsen the course of the disease.

Hypertensive crisis is a sharp increase in blood pressure, which is accompanied by disruption of target organs and the appearance of disorders of the autonomic nervous system.

The course of a hypertensive crisis can occur with or without complications. Complications include heart attacks, strokes, unstable angina, eclampsia, bleeding, arrhythmias, renal failure. An uncomplicated hypertensive crisis can be expressed in an uncomplicated cerebral form, an uncomplicated cardiac crisis, an increase in blood pressure up to 240/140 mm Hg. Art.

Diagnostics

There are three ways to determine high blood pressure:

Objective examination of the patient.
Blood pressure measurement.
Registration of an electrocardiogram.

Objective examination of the patient

During the medical examination, the heart is listened to using a phonendoscope. This method determines heart murmurs, weakened tones or, conversely, enhanced ones. In some cases, it is possible to hear other sounds uncharacteristic of cardiac activity, which is associated with increased pressure in the circulatory system.

The doctor must interview the patient to determine complaints, life history and illness. Special attention is paid to the assessment of risk factors and hereditary predisposition. In particular, if close relatives have arterial hypertension, the risk of developing this disease in the patient himself is high. A physical examination can also determine the patient's height, weight, and waist circumference.

Blood pressure measurement

Correct measurement of blood pressure makes it possible to avoid errors that may affect subsequent treatment tactics. For diagnostics, a working device is taken. Today, electronic and mechanical tonometers are more often used, but when using them, annual calibration must be carried out.

Rules for measuring blood pressure:

The patient must be in a calm state for at least 5 minutes before measuring blood pressure.
The patient should take a sitting position, on a chair or armchair, with his back resting on the backrest, and the hand on which blood pressure will be measured should be placed freely, palm up. In extreme cases, the patient’s blood pressure is measured while standing or lying down, but the main thing is that the arm is positioned freely
The cuff is installed at the level of the heart, 2-3 cm above the bend of the elbow, not tightened too much, but leaving room for the free passage of two fingers.
During mechanical measurement, air is pumped until the pulse in the radial artery can no longer be felt. After this, the cuff is inflated a little more and the air begins to be released little by little.

Systolic pressure is determined by the first knocking sounds (phase I of Korotkoff sounds), which appear and then gradually intensify.

Diastolic pressure is registered in the V phase of Korotkoff sounds, when the knocking sounds completely stop.

For normal blood pressure, the measurement is carried out once. If the pressure is above 120/80, then blood pressure testing is carried out two to three times with an interval of five minutes.

Video Algorithm for measuring blood pressure

Electrocardiogram registration

In arterial hypertension, left ventricular hypertrophy is often observed. Such a change can be recorded with maximum accuracy using electrocardiography. This non-invasive diagnostic method takes only a few minutes, after which the doctor deciphers the data obtained.

IN mandatory carry out next research:

General blood and urine tests.
Biochemical blood test with determination of microelements, sugar, cholesterol, creatinine.
Determination of hormone levels (aldosterone, adrenaline).
Fundus ophthalmoscopy.
Echocardiography.

If necessary, the diagnosis can be supplemented by Dopplerography, arteriography, ultrasound of the thyroid gland and internal organs (liver, kidneys).

Treatment

According to the 2003 recommendations of the American National Joint Committee compulsory treatment patients with high and extreme high risk on the development of arterial hypertension. If its level is moderate, patients are observed from several weeks to six months in order to obtain additional clinical data that will help in making a decision on treatment. drug treatment. Low-risk patients are observed for longer - up to 12 months.

Drug treatment is prescribed to reduce the risk of developing heart and vascular disease, as well as to prevent death. Additionally, methods are used to improve the quality of life of patients.

Main components of treatment:

Lifestyle changes.
Drug therapy.

Lifestyle change

First of all, patients with hypertension should give up bad habits such as smoking and drinking alcohol, which have a toxic effect on internal organs.

Body weight must be normalized, which can be greatly helped by increasing physical activity.

Dietary nutrition is an important component of the treatment of hypertension. In particular, salt intake should be limited to 6 g per day or less. The diet should be rich in foods rich in calcium and magnesium. Fatty foods and those that increase cholesterol should be completely excluded.

It is worth pointing out that it is important to avoid stressful situations, then the likelihood of dysfunction of the nervous system will be minimized.

Drug therapy

The algorithm for treating patients with arterial hypertension with medications largely depends on the severity of the disease.

In the first and second degrees, changes are made to the patient’s lifestyle and his condition is monitored. If a high or very high absolute risk is determined, treatment begins immediately.
In the third degree, drug therapy begins immediately, risk factors are additionally assessed, and target organs are determined. Lifestyle changes are used.

Prescription of drugs is carried out “not blindly”, but using an acute pharmacological test. It consists of the patient taking an average dose of the drug after a preliminary measurement of blood pressure. Then, after a short wait, blood pressure is measured again. If the drug is effective, it is used in long-term therapy.

The following drugs are used in the first line of therapy:

Diuretics.
Calcium antagonist
ACE inhibitors
Angiotensin II receptor antagonists
Beta blockers

In the second line, direct vasodilators, central alpha2 receptor agonists, and rauwolfia alkaloids can be prescribed.

In antihypertensive therapy, combinations of drugs from various pharmacological groups can be used. Which one to give preference is the decision of the attending physician who knows individual characteristics specific patient.

Prognosis and prevention

In arterial hypertension, a favorable prognostic conclusion can be made in cases where the disease was identified at an early stage of development, correct risk stratification was carried out and adequate treatment was prescribed.

Prevention of arterial hypertension can be of two types:

The primary one is to correct the lifestyle.
Secondary - based on the use of antihypertensive drugs; in addition, the patient must undergo clinical observation.

Scientific editor: Strokina O.A., practicing therapist, doctor functional diagnostics. Work experience since 2015
September, 2018

Arterial hypertension (hypertension, hypertension) is a condition in which blood pressure is equal to or exceeds 140 mm Hg. (as a result of at least three measurements taken at different times in a quiet environment; in this case, you should not take medications that either increase or decrease blood pressure).

If the causes of arterial hypertension can be identified, then it is considered secondary or symptomatic. If there is no obvious cause, it is called primary, or hypertension. The latter is much more common; more than 90% of people with high blood pressure suffer from it.

Arterial hypertension affects 30-45% of the adult population. Before the age of 50, the disease is more often observed in men, after 50 years - in women.

Reasons

The causes of arterial hypertension are currently far from completely clear. However, according to recent research, there are several main reasons:

Genetic predisposition;
In the development of the disease, both internal (hormonal, nervous system), and external factors (excessive consumption of table salt, alcohol, smoking, obesity);
Fat metabolism disorders;
Sugar diabetes;
Kidney diseases;
Stress;
Inactivity;
Smoking.

The following blood pressure levels are accepted by the World Health Organization:

How to measure pressure correctly

The ideal option for measuring blood pressure is considered mechanical tonometer and a phonendoscope. This method is as accurate as possible. But for self-monitoring at home, you can use an automatic or semi-automatic blood pressure monitor.

The measurement must be taken after a five-minute rest.
30 minutes before this, eating, drinking coffee, alcohol, physical activity, and smoking are not recommended.
When measuring, your legs should not be crossed, your feet should be on the floor, your back should rest on the back of the chair.
The hand needs support bladder must be emptied before measurement.

Failure to comply with these conditions may lead to an increase in blood pressure.

The shoulder should not be compressed by clothing (measuring through clothing is not acceptable). Blood pressure is measured at least twice on the same arm. If a difference in blood pressure level is detected in one arm of 5 or more mm Hg. carry out an additional, third, measurement. As a result, the average value is recorded. During the first measurement, the pressure is measured on both hands, and subsequently on the hand where it was higher. The difference in blood pressure on the left and right hand should not exceed 10 mm Hg. Art. Larger differences should raise red flags for upper extremity vascular disease.

Symptoms of arterial hypertension

The main symptom is headache, often upon awakening and, as a rule, in the occipital region.

Patients may also complain of dizziness, blurred vision, the appearance of spots before the eyes, tinnitus, palpitations, pain in the heart area, and shortness of breath.

Arterial damage occurs. Then cold extremities and intermittent claudication are added to the list of complaints.

Blood pressure exceeds 140 mm Hg. Art. (as a result of at least three measurements taken at different times in a quiet environment; in this case, you should not take medications that either increase or decrease blood pressure).

Often arterial hypertension does not have any manifestations.

A dangerous complication of arterial hypertension - hypertensive crisis, acute condition, which is characterized by a sudden pronounced rise in pressure. Most often, a hypertensive crisis occurs when the systolic pressure reaches 180 mmHg. Art. and above or diastolic 120 mm Hg. Art. and higher. This condition is accompanied by pronounced symptoms, including neurological ones, and often requires calling an ambulance.

Diagnostics

At the appointment, the doctor will first of all find out the complaints that bother the patient and collect an anamnesis (history of illnesses and life). Then he will definitely measure your blood pressure levels and conduct a full examination.

If arterial hypertension is suspected, blood pressure and pulse should be monitored for at least 1-2 weeks. If blood pressure is above 140/90 mm Hg. more than three times when measured at different times, we can talk about arterial hypertension.

Next, it is necessary to exclude the so-called symptomatic hypertension, when high blood pressure is a consequence of other diseases and conditions. To do this, you need to carry out the following laboratory and instrumental studies:

ECG (signs of increased workload on the heart, possible violations rhythm), general blood test and glucose test(exclusion or confirmation of diabetes mellitus) are mandatory in any case
Kidney ultrasound, general urine analysis, determination of the level of urea, creatinine in the blood are necessary to exclude the renal nature of the disease
Ultrasound of the adrenal glands is performed if a pheochromocytoma is suspected (a tumor of the adrenal gland that causes the most severe hypertensive crises)
Ultrasound of the thyroid gland, hormone analysis T3, T4 , TSH(hypertension may be one of the symptoms of thyrotoxicosis)
MRI of the brain(BP increases with tumors, adenomas pituitary gland)
You should also consult a neurologist and ophthalmologist about damage to target organs for arterial hypertension (brain and eye vessels).

Increased blood pressure is possible

with abnormalities in the development of blood vessels, for example, coarctation - narrowing of the aorta, or with narrowing of the lumen of blood vessels, for example subclavian arteries, atherosclerotic plaques in varying degrees(in these cases, the pressure on the right and left hands may be different),
when taking certain medications (glucocorticosteroids, oral contraceptives),
in women during menopause.

In the case of symptomatic hypertension, treatment is aimed at eliminating its cause.

Level determination cholesterol(+ lipid spectrum), liver parameters (ALT, AST) - to resolve the issue of prescribing statins (these are drugs for the treatment of atherosclerosis)
Knowing the levels of K and Na in the blood is necessary for prescribing diuretics
Test for microalbuminuria (most early sign kidney damage due to arterial hypertension)
An ECG will help identify contraindications to taking certain groups of drugs (beta blockers, calcium antagonists)
Echocardiography (ultrasound of the heart) to detect heart murmurs, as well as to identify various changes in the organ;
Ultrasound of brachiocephalic vessels (arteries and veins of the neck and head) for atherosclerosis
Ultrasound of the renal arteries to identify contraindications to the prescription of basic drugs for high blood pressure (ACE inhibitors)

Treatment of hypertension

The goal of treating hypertension is to reduce the risk of target organ damage (heart, brain, kidneys), because these organs suffer from high blood pressure first, even if there is no subjective discomfort No.

In young and middle-aged people, as well as in patients diabetes mellitus it is necessary to maintain pressure at a level of up to 140/90 mm Hg. For elderly people, the target blood pressure level is up to 150/90 mmHg.

The general principles of treatment of arterial hypertension are as follows:

For mild, first-degree disease, non-drug methods are used:

limiting table salt consumption to 5g/day (more about proper nutrition with high blood pressure can be read in our separate article),
normalization of excess weight,
moderate physical activity 3-5 times a week (walking, running, swimming, physical therapy),
smoking cessation,
reducing alcohol consumption,
use of herbal sedatives with increased emotional excitability (for example, a decoction of valerian).

If there is no effect from the above methods in the treatment of 1st degree arterial hypertension, as well as patients with 2nd and 3rd degrees of hypertension, proceed to taking medications.

It should be noted that pharmacies currently offer a wide range of different medications for the treatment of arterial hypertension, both new and known for many years. Drugs containing the same active ingredient may be produced under different trade names. It is quite difficult for a non-specialist to understand them, but despite the abundance of drugs, their main groups can be distinguished, depending on the mechanism of action:

Diuretics are the drugs of choice for the treatment of hypertension, especially in the elderly. The most common are thiazides (indapamide 1.5 or 2.5 mg per day, hypothiazide from 12.5 to 100 mg per day in one dose in the morning)

ACE inhibitors have been used for many years, are well studied and effective. These are such popular drugs as

enalapril (trade names Enap, Renipril, Renitek),
fosinopril (Fosinap, Fosicard),
perindopril (Prestarium, Perineva)
ramipril (Amprilan, Hartil), etc.

Sartans(or angiotensin II receptor blockers) are similar in mechanism of action to ACE inhibitors:

losartan (Lazap, Lorista),
valsartan (Valz),
irbesartan (Aprovel),
telmisartan (Telmista).

Beta blockers. Currently, highly selective drugs with minimal side effects are used:

bisoprolol (Concor, Niperten),
metoprolol (Egilok, Betalok),
nebivolol (Nebilet, considered the most selective of modern beta blockers), etc.

Calcium antagonists According to the mechanism of action, they are divided into 2 main groups, which is of great practical importance:

dihydropyridine (amlodipine, felodipine, nifedipine, nitrendipine, etc.)
non-dihydropyridine (verapamil, diltiazem).

Other drugs for the treatment of arterial hypertension are used strictly according to indications and in case of ineffectiveness of the above-described classes of medicinal substances:

moxonidine ( trade name Physiotens, Tenzotran).
doxazosin/prazosin (Cardura/Prazosin).

Also, when treating arterial hypertension, it is important to correct risk factors

antiplatelet agents - acetylsalicylic acid, (for example, Cardiomagnyl, Thrombo-ACC) are used according to indications,
statins in the presence of atherosclerosis - also in the absence of contraindications;
drugs that lower blood glucose levels in the presence of diabetes.

If the effect is insufficient, it may be necessary to add a second or third drug. Rational combinations:

diuretic+beta blocker
diuretic + ACE inhibitor (or sartan)
diuretic+calcium antagonist
dihydropyridine calcium antagonist + beta blocker
calcium antagonist + ACE inhibitor (or sartan)

Invalid combinations:

non-dihydropyridine calcium antagonist + beta blocker (possible development of heart block, even death)
ACEi+sartan

Currently available for sale large number so-called fixed combinations (2 or 3 active ingredients in one tablet, combining well with each other). Usage combination drugs increases adherence to treatment and facilitates blood pressure control. These include the following:

Lorista N, Lozap plus (lasartan + hydrochlorothiazide)
Valz N (valsartan+hydrochlorothiazide)
Prestans, Dalneva (perindopril + amlodipine in various dosages)
Exforge (valsartan+amlodipine) and Co-exforge (valsartan+amlodipine+hydrochlorothiazide), etc.

For treatment and examination for hypertension, you need to see a doctor. Only a specialist, after a full examination and analysis of the examination results, will be able to correctly diagnose and prescribe competent treatment.