Hypertensive crisis with a sharp increase in blood pressure (diastolic, as a rule, exceeds 120 mm Hg), is an exacerbation of the symptoms inherent in arterial hypertension. For her, as for many other diseases, periodic exacerbations, worsening of the condition, followed by remissions, often occurring without treatment, are characteristic. However, periods of exacerbation, lasting weeks, months, should not be called crises: the latter are more correctly attributed only to rapidly, sometimes suddenly developing, short-term (minutes, hours, less often days) worsening conditions accompanied by a marked increase in blood pressure, severe subjective symptoms and objective signs of acute neurohumoral disorders.
The increase in blood pressure can be due to two mechanisms: 1) vascular - an increase in total peripheral resistance due to an increase in vasomotor (neurohumoral effects) and basal (with sodium retention) arterioles tone; 2) cardiac - an increase in cardiac output due to an increase in heart rate, circulating blood volume, and myocardial contractility.
In the clinical picture of the crisis, symptoms associated with a sharp increase in blood pressure come to the fore (first of all, the speed of pressure increase is important - minutes or hours, but not days). As a rule, both systolic and diastolic blood pressure rises, but to a different degree, therefore, pulse pressure can increase and decrease.
With hypertensive crises, a headache intensifies sharply or appears. It can be paroxysmal and constant, dull and throbbing, can be localized in the neck, crown of the head or forehead and is most often caused by disorders of the blood supply to the brain. Dizziness , loss of balance, the feeling that "everything is floating around" are also frequent complaints of patients during a crisis. Often, headache and dizziness are combined with tinnitus. Brain symptoms of crisis include nausea and vomiting . Their combination with a headache with a serious general condition of the patient may indicate an increase in intracranial pressure and the development of cerebral edema. Visual impairment often accompanies the development of a crisis and is a consequence of changes in the fundus (spasm of the retinal vessels, swelling of the optic nerves). The degree of visual impairment can vary: from a grid of dark or light moving points in front of the eyes to short-term loss of vision.
Frequent complaints of patients during a hypertensive crisis include discomfort in the heart: pain, palpitations, interruptions, shortness of breath . The pains can be aching, stitching (like cardialgia), but often they have the character of typical intense compressive chest pains extending to the left hand, the shoulder blade, decreasing after taking nitroglycerin, and indicate the occurrence of an attack of angina pectoris. Less common are complaints of abdominal pain ("abdominal toad") and a symptom of intermittent claudication as a manifestation of vascular disorders in other organs.
Examination of the patient reveals a number of symptoms characteristic of a crisis. Signs of disturbed activity of the central and autonomic nervous system come to the fore. Patients are excited, irritable, the skin is moist, hyperemic. Often on the face, neck, chest red spots appear; chills, muscle tremors, temperature rises to subfebrile figures. In other cases, on the contrary, sharp depression of the nervous system is evident: lethargy, stupor, drowsiness. Muscular twitching and even epileptiform cramps can be observed, between which the patient is in a coma. Speech disorders, one-sided weakness and loss of pain sensitivity (in milder cases, crawling, tingling in the arms and legs - the so-called paresthesias) in the right or left limbs indicate transient focal disorders in the central nervous system.
Mandatory manifestation of hemodynamic. disturbances in crisis is only an increase in blood pressure. The rest of the picture of cardiovascular pathology is diverse. The pulse is often accelerated, but the feeling of a heartbeat may not be accompanied by tachycardia. Bradycardia is sometimes observed. Of rhythm disturbances, extrasystole is more common than others. Percussion borders of relative dullness of the heart, as a rule, are expanded to the left due to left ventricular hypertrophy, observed with prolonged arterial hypertension. With auscultation, a sharp emphasis is noted, sometimes splitting of the II tone above the aorta. If a hypertensive crisis occurs in a patient with pronounced organic changes in the heart, it is often possible to detect signs of acute heart failure: the pulse becomes frequent, and heart sounds are deaf, in the lower parts of the lungs voiced inactive congestive wheezing begins - an attack of cardiac asthma develops, in severe cases pulmonary edema ( more often it is left ventricular failure). On the ECG during a hypertensive crisis, there may be signs of systolic overload of the left ventricle in the form of depression of the ST segment and flattening of the T wave.
The various symptoms noted are often combined, causing the appearance of characteristic symptom complexes, which makes it possible to distinguish between two types of crises.
Crisis of the first type (hyperkinetic) is observed mainly in the early stages of arterial hypertension, develops acutely, is accompanied by excitement of patients, an abundance of “vegetative signs” (muscle tremors, increased sweating, red spots on the skin, palpitations, polyuria by the end of the crisis, sometimes profuse loose stools) and occur briefly (no more than 3-4 hours). These crises are characterized by a predominant increase in systolic blood pressure, an increase in pulse pressure, and an increase in heart rate. The first type of crises is characterized by a predominance of adrenaline in the blood, which, as you know, has the ability to increase metabolism, cause hyperglycemia, tachycardia, and an increase in systolic pressure.
The second type of crisis (hypokinetic), which occurs, as a rule, in the late stages of the disease against the background of a high initial level of blood pressure, is characterized by a less acute onset, more gradual development, relatively long (from several hours to 4-5 days) and severe course. These patients look lethargic, inhibited. They have particularly pronounced brain and heart symptoms. Systolic and diastolic pressure in these cases is very high, but the increase in diastolic pressure prevails, so the pulse pressure decreases slightly. There is no tachycardia or it is slightly expressed. For crises of the second type, the prevalence of norepinephrine in the blood is characteristic, which primarily increases peripheral vascular resistance and, accordingly, diastolic pressure.
Of course, the subdivision of hypertensive crises into two types is to some extent arbitrary: the crisis often proceeds with clinical signs, some of which are characteristic for the first type, and the other part for the second.
Possible complications: hypertensive encephalopathy, cerebral edema, characterized by headache, irregular dizziness, severe nausea and vomiting, convulsions, confusion, coma; acute cerebrovascular accident with the appearance of focal neurological disorders; eclampsia , the appearance of convulsive syndrome; heart failure development; the development of an attack of angina pectoris or myocardial infarction; stratification of an aortic aneurysm.
Thus, the diagnosis of hypertensive crisis is based on the following main criteria:1)
relatively sudden onset;2)
individually high rise in blood pressure;
3) subjective disorders and objective symptoms of cerebral, cardiac and autonomic nature.
Hypertensive crisis is classified as a condition that poses an immediate threat to the patient's life and requires emergency treatment. The initial goal of treatment is to reduce diastolic pressure to 100 mmHg. With vertebrobasilar insufficiency and signs of cerebral ischemia against the background of a hypertensive crisis, blood pressure should be reduced very carefully due to the risk of cerebrovascular accident. Since the decrease in pressure can nevertheless be sharp, the patient should be in a horizontal position.
Currently, there is a sufficient range of tools to quickly reduce blood pressure. It is advisable to start therapy of an uncomplicated crisis with taking 10 - 20 mg of nifedipine (Corinfar) under the tongue. In most cases, after 5 to 30 minutes a significant drop in blood pressure begins (by 20 to 25%) and patients' well-being improves. In the absence of effect, nifedipine can be repeated. The duration of the drug taken in this way is 4–5 hours. In the case of the hyperkinetic variant of the crisis, 20–40 mg of anaprilin is prescribed under the tongue (intravenous administration is possible provided that blood pressure and heart rate are monitored in a specialized unit). From distracting procedures, mustard plasters are used on the back of the head, on the lower back and to the legs, cold to the head with severe headaches, hot foot baths.
Parenteral administration of drugs is indicated for the development of encephalopathy, eclampsia, heart failure or myocardial infarction against the background of a hypertensive crisis, with exfoliating aortic aneurysm, and the inefficiency of taking nifedipine under the tongue. Since the clinical picture of hypertensive crises and their complications is diverse, various symptomatic agents are also used.
With severe patient agitation, drugs are shown that have a sedative and hypnotic effect: droperidol (2 ml of a 0.25% solution intravenously), seduxen (10 mg - 2 ml intramuscularly or intravenously). Seduxen is especially indicated for the complication of hypertensive crisis by the development of convulsive syndrome.
With severe neurological symptoms, it is advisable to use dibazole (5-10 ml of a 0.5% solution) and magnesium sulfate. The latter has a vasodilator, sedative, anticonvulsant effect, reduces cerebral edema. Since a quick therapeutic effect is required, the drug is administered intravenously slowly (for elderly patients, especially carefully, as breathing problems are possible) at a dose of 10-15 ml of a 25% solution. Intramuscular administration is undesirable not only because of low efficiency, but also due to the high risk of developing abscesses. Eufillin (10 ml of a 2.4% solution intravenously in a stream or drip) is also indicated for complications of the crisis with cerebral disorders. The drug reduces blood pressure and stimulates the central nervous system, has a moderate diuretic effect. Elderly patients are administered with caution in view of the possibility of an increase in heart rate and the development of arrhythmias.
Diuretics have a good antihypertensive effect due to the intensive elimination of sodium chloride. Their use is especially shown in the picture of cerebral edema or acute left ventricular failure accompanying a crisis. Lasix (furosemide) is administered intravenously (2 - b ml), furosemide - 40 mg per tongue. Diuretic drugs do not replace, but complement and enhance the action of other antihypertensive drugs.
In the case of a hypertensive crisis complicated by severe angina pectoris, the development of myocardial infarction, or acute left ventricular failure, sublingual or intravenous drip of nitrates (nitroglycerin or isosorbide dinitrate) is indicated.
The treatment of hypertensive crisis provides, in addition to the use of effective antihypertensive drugs, distracting procedures, soothing and symptomatic therapy, the creation of complete physical and mental rest for the patient. Since immediate administration of drugs lowering blood pressure is required, treatment begins where the diagnosis is made: at a medical station, at home, in an ambulance, in the emergency room. When a hypertensive crisis occurs for the first time in life, when its course is complicated, and when it is impossible to provide full-fledged medical care on the spot, the patient must be hospitalized urgently: maximum rest is only a background for active therapy.