Arterial hypertension

Arterial hypertension is the increase in blood pressure from the aortic orifice to the arterioles inclusive. In practical work, the doctor (and, accordingly, the patient) is guided by the values ​​of the so-called "random" pressure, measured in the patient after a five-minute rest, in the sitting position. The shoulder on which the cuff is applied should be at heart levels, the rubber cuff reservoir should cover at least 2/3 of the shoulder, the cuff should not crawl on the elbow. Blood pressure (BP) is measured three times in a row and takes into account the lowest values. In adults, diastolic blood pressure corresponds to the V phase of Korotkov (disappearance of tones), in children - to the IV phase (sharp weakening of tones). At the first examination of the patient the doctor is obliged to measure BP on both hands, and with the appropriate indications, and on the legs.

In healthy people, 20 to 40 years of age, "random" BP is usually below 140/90 mm Hg. Art. , In individuals aged 41 to 60 years - below 145/90 mm Hg. Art. , In healthy people older than 60 years systolic pressure in most cases does not exceed 160, and diastolic pressure - 90 mm. Gt; Art. It is necessary to distinguish between sporadic (situational), acute moderate increases in blood pressure and chronic, often recurrent elevations of blood pressure. If the former can reflect physiological reactions, the latter go beyond them.

There is a primary arterial hypertension (AH) and secondary AH. Within the boundaries of the primary hypertension, the existing disease, called essential hypertension, or hypertension, is distinguished, and the state of unstable regulation of AD with a tendency toward its transient small increases (this condition is called borderline hypertension).

Secondary (symptomatic) hypertension is about 10% of all cases of chronic or often recurring elevation of both systolic and diastolic blood pressure. Their occurrence is associated with damage to organs or systems that have a direct or indirect effect on blood pressure. Increasing blood pressure is one of the symptoms of the disease of these organs or systems. Elimination of the etiological or leading pathogenetic factor often leads to normalization or to a marked decrease in blood pressure. Depending on the involvement in the process of increasing the BP of a particular organ, secondary hypertension is classified as follows: 1) renal: a) parenchymal, b) Renovascular: 2) endocrine; 3) hemodynamic (cardiovascular, mechanical); 4) neurogenic (focal); 5) the rest.

To the group of renal parenchymatous arteries belong to AG in acute and chronic glomerulonephritis and pyelonephritis, polycystic kidney, congenital or acquired obstructive hydronephrosis, kidney anomalies, diabetic glomerulosclerosis, lupus nephritis, kidney with radiation sickness, etc. Renovascular hypertension (2-5% of all AH) can be congenital (for example, in cases of fibro-muscular dysplasia of the renal arteries) and acquired (more often as a result of atherosclerotic narrowing of the renal arteries or nonspecific aortoarteritis).

Endocrine AH (about 2% of all hypertension) is due to pheochromocytoma and other chromaffin tumors (paragangliomas), primary aldosteronism (Cohn's syndrome), Disease and Cushing's syndrome, acromegaly, and others.

Hemodynamic, or cardiovascular, AH arise as a result of changes in hemodynamics, mainly due to mechanical factors. These include systolic hypertension in atherosclerosis of the aorta, insufficiency of the aortic valves, open arterial duct, arteriovenous fistulas, complete AV blockade, Paget's disease, thyrotoxicosis (some authors refer this form to endocrine-type AH), systolic-diastolic AH of the hemodynamic type develops with coarctation of the aorta.

Neurogenic hypertension (about 0.5% of all hypertension) occurs in focal lesions and diseases of the brain and spinal cord (tumors, encephalitis, bulbar poliomyelitis, quadriplegia - hypertensive crises), with the excitation of the vasomotor center of the medulla oblongata caused by hypercapnia and respiratory acidosis. The "remaining" AH can include symptomatic AH in patients with polycythemia, carcinoid syndrome, acute porphyria, lead poisoning, thallium, prednisolone overdose, catecholamines, ephedrine, "cheese disease", along with MAO inhibitors (iprazid) Tyramine (some sorts of cheese and red wine). This group also includes AH in women with late toxicosis of pregnant women, as well as AH, which occurs in women taking hormonal contraceptives.

Symptoms and treatment of secondary hypertension are similar in many respects to those in hypertensive disease. But in a number of diseases, etiological treatment is possible: surgical removal with pheochromocytoma, adrenal adrenal, reconstructive operations on the vessels of the kidneys, aorta, arteriovenous fistulas; Abolition of drugs that increase blood pressure, and others.

Border AG is a type of primary hypertension in young and middle-aged people characterized by fluctuations in blood pressure from the norm to the so-called border zone: 140/90-159/94 mm Hg. Art. Slightly elevated and normal values ​​of blood pressure change each other, the normalization of blood pressure occurs spontaneously. There are no typical target lesions for hypertensive disease: hypertrophy of the left ventricle, changes in the fundus, kidneys, and brain. Increases in blood pressure of the borderline type occur in about 20-25% of adults, and up to 50 years they are more often recorded in men. Only 20-25% of persons with borderline AH become ill with further hypertension (GB); In about 30% of people, fluctuations in blood pressure in the border zone may persist for many years or a lifetime; The rest of the blood pressure is normalized over time.

Hypertensive disease (HB), together with borderline AH, accounts for up to 90% of all cases of chronic BP elevation. Currently, in economically developed countries, about 18-20% of adults suffer from GB, i.e., have repeated increases in blood pressure to 160/95 mm Hg. Art. and higher.

Etiology and pathogenesis. The reasons for the formation of GB are not established with certainty, although some parts of the pathogenesis of this disease are known. It should be considered with participation in the development of GB two factors: norepinephrine and sodium. Norepinephrine, in particular, is assigned the role of an effector agent in GF Lang's theory of the decisive role of mental overstrain and mental trauma for the onset of GB. There is agreement that for the formation of GB, a combination of hereditary predisposition to a disease with unfavorable external influences on a person is necessary. Epidemiological studies confirm the existence of a link between the degree of obesity and increased blood pressure. However, the increase in body weight should rather be attributed to the number of predisposing factors than the causal factors themselves.

Symptoms, course. The disease rarely begins streets younger than 30 years and older than 60 years. Stable systolic diastolic hypertension in a young person is the basis for persistent search for secondary, in particular, renovascular hypertension. High systolic pressure (above 160-170 mm Hg) with normal or decreased diastolic pressure of streets older than 60-65 years is usually associated with atherosclerotic aortic compaction. GB proceeds chronically with periods of deterioration and improvement. The progression of the disease may be different in tempo. Distinguish slowly progressive (benign) and quickly progressing (malignant) course of the disease. With a slow development of the disease passes through 3 stages according to the classification of GB, adopted by WHO. The fragmentation of stages in the sub-stage is not advisable.

Stage / (lung) is characterized by comparatively small elevations of blood pressure in the range 160-179 (180) mm Hg. Art. Systolic, 95-104 (105) mm Hg. Art. - diastolic. The level of blood pressure is unstable, during the rest of the patient it gradually normalizes, but the disease is already fixed (in contrast to border AH), the increase in blood pressure is inevitably returned. Some patients do not experience any state of health disorders. Others are concerned about headaches, noise in the head, sleep disturbances. Decreased mental performance. Occasionally there are non-systemic dizziness, nosebleeds. Usually there are no signs of left ventricular hypertrophy, the ECG deviates little from the norm, sometimes it reflects the state of hypersympathicotonia. Kidney functions are not dried; The fundus is practically unchanged.

Stage II (mean) differs from the previous one by a higher and more stable level of blood pressure, which at rest is within 180-200 mm Hg. Art. Systolic and 105-114 mm Hg. Art. Diastolic. Patients often complain of headaches, dizziness, pain in the heart, often of a stenocardic nature. For this stage hypertensive crises are more typical. There are signs of damage to target organs: hypertrophy of the left ventricle (sometimes only the interventricular septum), weakening of the I tone at the apex of the heart, accent of the 2nd tone on the aorta, in some patients - on ECG signs of subendocardial ischemia. From the side of the central nervous system there are various manifestations of vascular insufficiency; Transient ischemia of the brain, cerebral strokes are possible. On the fundus, in addition to the narrowing of the arterioles, there are compression of the veins, their expansion, hemorrhage, exudates. Kidney blood flow and glomerular filtration rate are reduced, although there are no abnormalities in urinalysis.

Stage III (severe) is characterized by a more frequent occurrence of vascular accidents, which depends on a significant and stable increase in blood pressure and the progression of arteriolosclerosis and atherosclerosis of larger vessels. The blood pressure reaches 200-230 mm Hg. Art. Systolic, 115-129 mm Hg. Art. Diastolic. Spontaneous normalization of blood pressure does not happen. The clinical picture is determined by cardiac damage (angina, myocardial infarction, circulatory insufficiency, arrhythmias), the brain (ischemic and hemorrhagic infarctions, encephalopathy), the fundus (angioretinopathy II, III types), kidneys (decreased renal blood flow and glomerular filtration). In some patients with stage 111 of GB, despite a significant and sustained increase in blood pressure, severe vascular complications do not occur for many years.

In addition to the stages of GB, reflecting its severity, several clinical forms of GB are distinguished. One of them is the hyperadrenergic form, which is more often manifested in the initial period of the disease, but can persist throughout its course (about 15% of patients). Typical for it are signs such as sinus tachycardia, unstable blood pressure with a predominance of systolic hypertension, sweating, eye shine, reddening of the face, sensation of patients with pulsations in the head, palpitations, chills, anxiety, inner tension. Hyperhydration form of GB can be recognized by such characteristic manifestations as periorbital edema and puffiness of the face in the morning, swelling of the fingers, numbness and paresthesia, diuresis with transient oliguria, water-salt hypertensive crises, relatively fast delay of sodium and water treatment with sympatholytic Means (reserpine, dopegit, clonidine, etc.).

Malignant form of GB is a rapidly progressive disease with a rise in blood pressure to very high levels, which leads to the development of encephalopathy, visual impairment, pulmonary edema and acute renal failure. At present, malignant current GB is extremely rare, a malignant final of secondary hypertension (renovascopyarnoy, pyelonephritic, etc.) is much more often noted.

Treatment. Can be carried out with the help of non-pharmacological and pharmacological methods. Nonpharmacological treatment includes: a) weight loss due to a decrease in fat and carbohydrate diet, b) restriction of consumption of table salt (4-5 g per day, and with a tendency to delay sodium and water 3 grams per day, the total amount of fluid consumed - 1.2-1.5 liters per day), c) spa treatment, methods of physiotherapy and physiotherapy, d) psychotherapeutic effects. In themselves, non-pharmacological methods of treatment are effective mainly in patients with stage 1 disease. But they are constantly used as a background for successful pharmacological treatment and at other stages of the disease.

Pharmacological treatment is based on the so-called "step" principle, which involves the appointment in a certain sequence of drugs with different points of application of their action until the moment of normalization of blood pressure, and in case of failure - the transition to an alternative plan.

Antihypertensive treatment in the volume of the first stage is indicated for patients with mild GB course (stage 1). Assign one oral medication: a beta-blocker or diuretic. The beta-adrenergic receptor blocker is preferred if the patient has an increase in heart rate, increased heart rate and other signs of hypersympathicotonia, weight loss, dehydration, propensity to hypokalemia, or an increase in the concentration of uric acid in the blood. The initial dose of anaprilin is 80 mg per day (divided into two doses); Decrease in pulse to 70-60 in 1 min comes in 2-3 days, and persistent lowering of blood pressure by the end of the first and beginning of the second week of treatment. In the future, the dose of anaprilin may be somewhat reduced, or patients take the drug every other day, etc. (with mandatory blood pressure testing). Instead of anaprilin, can be used in a dose of 5 mg 1 -2 times a day. This beta-blocker is more indicated for patients who have a tendency to decrease their pulse in the initial period, as well as to people with liver and kidney disease.

Diuretics at the first stage of treatment with GB are preferred in its hyperhydration form, sinus bradycardia, vasospastic reactions, chronic bronchopulmonary diseases, obesity. Hypothiazide in a dose of 25 mg patients are taken once a day in 2-3 days, these intervals between hypothiazide can be prolonged with normalization of blood pressure.

If there are contraindications to the appointment of beta-adrenoblocker and diuretics, then at the first stage of treatment, sympatholytic drugs are used: clonidine (0.15 mg in the afternoon), dopegit (250 mg 2 times a day). These drugs are shown to patients with diabetes mellitus, bronchial asthma, hypokalemia, gout. In patients with stage I hypertension, the normalization of BP occurs quickly enough, therefore, intermittent courses of treatment are allowed, provided that blood pressure is measured quite often.

Treatment in the volume of the second stage is intended for patients with moderate severity GB (stage II) or in those cases when monotherapy was ineffective. Patients should take two drugs: a) anaprilin (40 mg 3-4 times a day) + hypothiazide (25-50 mg once a day); B) Viskin (5 mg 3 times a day) + hypothiazide (in the same dose); C) clonidine (0.15 mg 2-3 times a day) + hypothiazide (in the same dose); D) dopegit (250 mg 3 times a day) + hypothiazide (in the same dose); E) Reserpine (0.1 mg - 0.25 mg per night) + hypothiazide (in the same dose).

When choosing these combinations take into account contraindications, possible side effects of drugs, the interaction of drugs. The latter circumstance is very important, for example, antidepressants and antipsychotics do not suppress the effects of beta-adrenoblockers, but significantly limit the effect of guanethidine, dopegit, clonidine. However, beta-blockers in large doses can cause nightmares, sleep disturbances. Reserpine and its analogs are contraindicated in patients with Parkinsonism, certain mental illnesses.

After lowering the blood pressure, the doses of the drugs can be reduced. In a time that is favorable for the patient, short-term omissions in the administration of one or the other drug are allowed. However, unlike the first stage, the therapy here becomes systematic, not a course. The combination of two drugs provides normalization of blood pressure in 2/3 patients. Long-term use of a diuretic can cause hypokalemia, so patients should periodically take aspirin (panangin) 1 tablet 3 times a day or another potassium preparation. In some patients, as a result of the systematic use of diuretics, the concentration in the plasma of triglycerides and, to a lesser extent, cholesterol, increases, which requires medical supervision. People with diabetes mellitus or people with reduced tolerance to glucose load instead of diuretics (hypothiazide, brinapidix, chlorthalidone, etc.) are prescribed veroshpiron 250 mg 2-3 times a day for 15 days with interruptions of 5 days.

Treatment in the volume of the third stage is indicated for patients with severe course of GB (stage III) or with the emergence of resistance to two drugs. The therapeutic program includes three drugs in various combinations and doses: sympatholytic, diuretic and peripheral vasodilator. Be sure to take into account contraindications for each of the antihypertensive drugs. The widely used combination drugs adenaphane, trirezite-K, cristerin (brinerdin), and a number of others are suitable for use in patients with stage III GB or in those patients with Stage II GB who have not responded enough to a diuretic and sympatholytic. Of the peripheral vasodilators, corinfar (phenygidine) is often given 10 mg 3-4 times a day or apressin (hydralazine) 25 mg 3-4 times a day. In recent years, alpha-blockers have been successfully introduced into treatment regimens instead of peripheral vasodilators. For example, prazosin (pratsiol) is prescribed in an initial dose of 1 mg 2-3 times a day. The dose can be (if necessary) slowly increased within 2-4 weeks to 6-15 mg per day. It is necessary to remember the ability of prazosin to cause orthostatic hypotension. Another alpha-blocker phentolamine patients are taken with a beta-blocker in a dose of 25 mg 3 times a day. Very effective is the combination of vine (15 mg per day), phentolamine (75 mg per day) and hypothiazide (25 mg per day).

There are other, alternative ways to treat GB at the third stage. Assign labetalol hydrochloride (trandate), combining beta-, and alpha-adrenergic activity; The initial dose for oral administration is 100 mg 3 times a day, then the dose can be increased to 400-600 mg per day. The combination of labetalol and diuretic virtually replaces the use of three antihypertensive drugs. Captopril - an angiotensin converting enzyme blocker - is prescribed mainly for patients with severe GB, and also with its complication with congestive circulatory insufficiency. Captopril at a dose of 25 mg 3-4 times a day, together with a diuretic, in many cases contributes to the achievement of complete control over blood pressure and significant clinical improvement. The full effect is revealed by the 7th-10th day of therapy.

Treatment in the volume of the fourth stage is carried out if the goal at the previous stage is not reached, as well as with the rapid progression of the disease or the development of malignant hypertensive syndrome. Assign two sympatholytic (often guanethidine in increasing doses), in large doses of furosemide, peripheral vasodilator or alpha-adrenoblocker. Among the latter, apricine (up to 200 mg per day), pratsiol (up to 15 mg per day), captopril (75-100 mg per day), diazoxide (up to 600-800 mg per day) are preferable. It should be borne in mind that with a decrease in glomerular filtration to 30-40 ml / min and an increase in creatinine concentration in the blood, thiazide diuretics and their analogues are ineffective and cause further damage to the kidneys.

Treatment of patients at the first-second stages is often carried out on an outpatient basis. If there are difficulties in the selection of effective drugs, patients are placed in the hospital for 2-3 weeks. At the third stage of treatment, it is better to start the choice of the drug regimen in a specialized cardiology unit.

Prognosis in GB B. Epidemiological observations show that even moderate BP increases several times the risk of future cerebral stroke and myocardial infarction. The frequency of vascular complications depends on the age at which a person develops GB. The prognosis for the young is more burdensome than for those who are sick in middle age. In the equivalent stage of GB, women experience less vascular disasters than men. Isolated systolic hypertension also increases the risk of stroke. Early treatment and effective continuous monitoring of blood pressure significantly improve the prognosis.