Hypertensive Crises

Hypertensive crises occur in hypertensive disease. In most cases, characterized by a combination of systemic and regional, mainly cerebral, angiodystonia, the type and ratio of which in each case determine the pathogenetic and clinical features of the crisis (clinico-pathogenetic variant thereof).

There are five variants of hypertensive crises, of which the most common are three: hypertensive cardiac crisis, cerebral angiogipotonic crisis and cerebral ischemic crisis. Rare include a cerebral complex crisis and a generalized vascular crisis. Common to all hypertensive crises is their connection with the "twitch" of the nervous regulation of gepodinamika (due to stress, weather change, tobacco abuse, physical overstrain, etc.).

Diagnosis of individual clinical and pathogenetic variants of crises, important for choosing the means of their optimal emergency therapy, is based on identifying distinct clinical symptoms or syndrome for each variant and does not require the use of instrumental research methods.

Hypertensive cardiac crisis is characterized by acute left ventricular heart failure with a sharp increase in blood pressure - usually above 220/120 mm Hg. Art. At lower levels of AD, the development of such a crisis is possible with some symptomatic forms of hypertension (renal form, paroxysmal hypertension in pheochromocytoma). The early signs of the crisis include complaints of anxiety, which appeared against the background of a significant increase in blood pressure. Later, a tendency to tachycardia, weakening of the heart's tone, a leveling of the volume of the second heart tone over the aorta and pulmonary artery trunk, the appearance of dyspnea are revealed. Symptoms of the unfolded phase of the crisis (right up to the pulmonary edema) and its medicamental therapy are presented in the table. The differential diagnosis is carried out in two directions: first, the primary pathology of the heart - acute myocardial infarction, myocarditis (by ECG, cardiospecific enzyme activity of blood, etc.), and secondly, diseases with symptomatic arterial hypertension, primarily pheochromocytoma, with Which is contraindicated in the use of ganglion blockers and sympatholytics.

Cerebral angiohypotonic crisis corresponds to the so-called hypertensive encephalopathy due to the overgrowth of intracranial veins and venous sinuses with blood with increasing pressure in the capillaries of the brain, which leads to edema-swelling of the brain, an increase in intracranial pressure. At the heart of the crisis, an inadequate tonic reaction of the arteries of the brain in response to an increase in blood pressure, which causes Ђprosolution избы of excessive blood flow to the brain under high pressure, as well as hypotension of the veins of the brain, complicating outflow. The main distinctive symptom of the crisis is a typical headache: it is localized at first in the occipital region, radiates into the retroorbital spaces (feeling of pressure over the eyes, behind the eyes), then becomes diffuse; Intensified in situations that make it difficult to drain blood from the veins of the head (horizontal position, straining, coughing, tight collar, etc.), decreases (in the early stages of development) with the vertical position of the tepah after taking the drinks containing caffeine. The diagnosis of a crisis requiring urgent care is established from the moment of irradiation of the occipital pain into retroorbital spaces, after which the intensity of pain rapidly increases, it becomes diffuse, painful. In the late phase of the crisis, there are various vegetative disorders, most often nausea, then repeated attacks of vomiting, which temporarily relieve the patient's health. There is an injection of vessels of the sclera and conjunctiva, sometimes cyanotic hyperemia of the face; Nephrologic disorders (inhibition, dissociation of reflexes on the upper and lower extremities, nystagmoid movements of the eyeballs, etc.) are defined. The crisis often begins with a moderate increase in blood pressure, for example, up to 170/100 mm Hg. Gt; ; It increases with the development of the crisis to 220/120 mm Hg. Art. And more, but sometimes even in the late phase does not exceed 200/100 mm Hg. Art. (The leading importance of regional angiodystonia).

The cerebral ischemic crisis is caused by an excessive tonic reaction of the cerebral arteries in response to an extraordinary increase in blood pressure (sometimes the systolic pressure is higher than the maximum of the scale of the tonometer). Distinguishing clinical symptoms - focal neurological disorders, dependent on the zone of cerebral ischemia; They appear in the late phase of the crisis. They are often preceded (sometimes in a few hours) by the symptoms of diffuse ischemia of the cerebral cortex, expressed by euphoria, irritability, which are replaced by depression, tearfulness; Sometimes there is aggression in behavior. In this phase of the crisis, the patient's uncritical attitude toward his condition is often noted, which makes early diagnosis difficult. From the dynamic disturbance of cerebral circulation, the crisis differs only in lesser degree and relative short duration of focal neurological disorders (less than a day).

Cerebral complex crisis is characterized by the appearance of focal neurological disorders in the midst of clinical manifestations of angiogipotonic crisis, less often in the initial phase of its development. In the latter case, the leading pathogenesis of the crisis is the pathological opening of arteriovenous anastomoses in the brain, which contributes to the overgrowing of the veins and leads to focal ischemia due to the phenomenon of "robbing" capillaries.

The generalized vascular crisis, in addition to the extraordinary increase in blood pressure with pronounced diastolic hypotension, is characterized by poly-regional angiodystonia with signs of blood supply disorders at the same time in several organs: the brain (headache, neurological disorders), retina (visual disorders with loss of visual fields), the heart (angina, arrhythmias), kidneys (Pro-theuria, hematuria). Often develops and acute left ventricular failure of the heart.

Treatment: a mentally sparing situation for the patient, the immediate administration of seduxen (or droperidol) and high-speed antihypertensive drugs, selected depending on the severity of the crisis, blood pressure level and pharmacological history data; The use of vasoactive and symptomatic agents in accordance with the clinical pathogenetic version of the crisis. The initial type of hemodynamics (hyper- or hypokinetic) in most cases is not critical for the choice of an antihypertensive drug, but in a cardiac crisis preference is given to peripheral vasodilators that do not reduce cardiac output.

Approximate tactics of emergency drug therapy in the main variants of hypertensive crises are presented in Table. 6. In case of cerebral complex crisis, vasoactive agents are preferred to a devincan or a combination of no-shpa with euphyllin; Symptomatic therapy coincides with that in the cerebral agiogipotonic crisis. In generalized vascular crisis, antihypertensive therapy is started with intravenous administration of clofainin with furosemide, with insufficient effect, ganglion blockers are administered (dropwise intravenously with control blood pressure measurements at least every 2 minutes).