All you need to know about arterial hypertension in one article

Arterial hypertension (essential hypertension) is the most common disease of the cardiovascular system. Hypertension refers to persistently high blood pressure. An increase in blood pressure occurs when there is a narrowing of the arteries and/or their smaller branches - arterioles. In some people, arterioles often narrow, at first due to spasm, and later their lumen remains constantly narrowed due to thickening of the wall, and then, in order for the blood flow to overcome these narrowings, the work of the heart increases and more blood is thrown into the vascular bed. Such people, as a rule, develop hypertension.

Approximately 40% of the adult population has an increased level of blood pressure. At the same time, about 37% of men and 58% of women know that they have a disease, and only 22 and 46% of them are being treated. Only 5.7% of men and 17.5% of women control their blood pressure properly.

Arterial hypertension is a chronic disease, accompanied by a persistent increase in blood pressure above acceptable limits (systolic pressure above 139 mm Hg or/and diastolic pressure above 89 mm Hg).

In about one in ten hypertensive patients, high blood pressure is caused by damage to an organ. In these cases, they speak of secondary or symptomatic hypertension. About 90% of patients suffer from primary or essential hypertension. The starting point for high blood pressure is at least three times the level of 139/89 mm Hg and more recorded by the doctor in people who are not taking blood pressure medications.

Arterial pressure

There are two indicators of blood pressure:

- Systolic blood pressure (SBP) - reflects the pressure in the arteries, which is created when the heart contracts and the release of blood into the arterial part of the vascular system;
- Diastolic blood pressure (DBP) - reflects the pressure in the arteries at the moment of relaxation of the heart, during which it is filled before the next contraction.

The World Health Organization has adopted the following blood pressure levels:

Symptoms of arterial hypertension

Clinic manifestations of hypertension have no specific symptoms. For many years, patients may not be aware of their illness, have no complaints, have high vitality, although sometimes attacks of "lightheadedness", severe weakness and dizziness may occur. But even then everyone thinks that this is from overwork. Although it is at this moment that you need to think about blood pressure and measure it. Complaints in hypertension occur if the so-called target organs are affected, these are the organs most sensitive to increases in blood pressure. The occurrence of dizziness, headaches, noise in the head, a decrease in memory and performance in a patient indicate initial changes in cerebral circulation. This is then joined by double vision, flashing flies, weakness, numbness of the limbs, difficulty speaking, but at the initial stage, changes in blood circulation are of an incoming nature. A far advanced stage of arterial hypertension can be complicated by a cerebral infarction or cerebral hemorrhage. The earliest and most permanent sign of constantly high blood pressure is an increase, or hypertrophy of the left ventricle of the heart, with an increase in its mass due to thickening of heart cells, cardiomyocytes.

First, the wall thickness of the left ventricle increases, and later this chamber of the heart expands. It is necessary to pay close attention to the fact that left ventricular hypertrophy is an unfavorable prognostic sign. A number of epidemiological studies have shown that the appearance of left ventricular hypertrophy significantly increases the risk of sudden death, coronary heart disease, heart failure, and ventricular arrhythmias. Progressive left ventricular dysfunction leads to symptoms such as shortness of breath on exertion, paroxysmal nocturnal dyspnea (cardiac asthma), pulmonary edema (often in crises), chronic (congestive) heart failure. Against this background, myocardial infarction and ventricular fibrillation develop more often.

In case of gross morphological changes in the aorta (atherosclerosis), it expands, and its stratification and rupture can occur. Kidney damage is expressed by the presence of protein in the urine, microhematuria, cylindruria. However, renal failure in hypertension, if there is no malignant course, rarely develops. Damage to the eyes can manifest itself as deterioration in vision, a decrease in light sensitivity, the development of blindness. Thus, it is quite obvious that hypertension should be treated more carefully.

Risk factors for arterial hypertension

Unchangeable risk factors include:

- Heredity - people who have hypertensive patients among their relatives are most susceptible to developing this pathology.
- Male sex - it was found that the incidence of arterial hypertension in men is significantly higher than the incidence of women. And the fact is that female sex hormones, estrogens prevent the development of hypertension. Unfortunately, such protection is short-lived. The post menopausal period sets in, the salutary effect of estrogens ends, and women become equal in morbidity with men and are often overtaken by them.

Variable risk factors include:

- Overweight - overweight people have a higher risk of developing arterial hypertension;
- A sedentary lifestyle - otherwise physical inactivity, a sedentary lifestyle and low physical activity lead to obesity, which in turn contributes to the development of hypertension;
- Alcohol consumption - excessive alcohol consumption contributes to arterial hypertension.
- Eating a lot of salt in food - a high-salt diet increases blood pressure. This raises the question of how much salt can be consumed per day? The answer is short: 4.5 grams or a teaspoon without top.
- Unbalanced diet with an excess of atherogenic lipids, excess calories, leading to obesity and contributing to the progression of type II diabetes. Atherogenic, i.e., literally, "atherosclerosis-creating" lipids are found in large quantities in all animal fats, meat, especially pork and lamb;
- Smoking is another changeable and significant factor in the development of arterial hypertension and its complications. The fact is that the substances of tobacco, including nicotine, create a constant spasm of the arteries, which, being fixed, leads to stiffness of the arteries, which entails an increase in pressure in the vessels;
- Stress - leads to the activation of the sympathetic nervous system, which acts as an instant activator of all body systems, including the cardiovascular system. In addition, pressor hormones, i.e., hormones that cause spasm of the arteries, are released into the blood. All this, as with smoking, leads to stiffness of the arteries and arterial hypertension develops;
- Gross sleep disorders such as sleep apnea syndrome, or snoring. Snoring is a real scourge of almost all men and many women. Why is snoring dangerous? The fact is that it causes an increase in pressure in the chest and abdominal cavity. All this is reflected in the vessels, leading to their spasm. Arterial hypertension develops.

Causes of arterial hypertension

The cause of the disease remains unknown in 90-95% of patients - it is essential (that is, primary) arterial hypertension. In 5-10% of cases, an increase in blood pressure has an established cause - it is symptomatic (or secondary) hypertension.

Causes of symptomatic (secondary) arterial hypertension:

- Primary kidney damage (glomerulonephritis) - the most common cause of secondary arterial hypertension;
- Unilateral or bilateral narrowing (stenosis) of the renal arteries;
- Coarctation (congenital narrowing) of the aorta;
- Pheochromocytoma (a tumor of the adrenal glands that produces adrenaline and norepinephrine);
- Hyperaldosteronism (a tumor of the adrenal gland that produces aldosterone);
- Thyrotoxicosis (increased thyroid function);
- Consumption of ethanol (alcohol) more than 60 ml per day;
- Medicines: hormonal drugs (including oral contraceptives), antidepressants and others.

Risk factors for cardiovascular complications in arterial hypertension

Basic:

- Men over 55;
- Women over 65;
- Total blood cholesterol> 6.5 mmol/L, increased low-density lipoprotein cholesterol (> 4.0 mmol/L) and low high-density lipoprotein cholesterol;
- Family history of early cardiovascular disease (women <65 years old, men <55 years old);
- Abdominal obesity (waist measurement ≥102 cm for men or ≥ 88 cm for women);
- Level of C - reactive protein in the blood ≥1 mg/dL;
- Diabetes mellitus (fasting blood glucose> 7 mmol/l).

Additional:

- Impaired glucose tolerance;
- Low physical activity;
- Increased fibrinogen levels.

Note: The accuracy of determining the general cardiovascular risk directly depends on how complete the clinical and instrumental examination of the patient was.

Complications of arterial hypertension

The most significant complications of arterial hypertension include:

- Hypertensive crises;
- Disorders of cerebral circulation (hemorrhagic or ischemic strokes);
- Myocardial infarction;
- Nephrosclerosis (primary contracted kidney);
- Heart failure;
- Dissecting aortic aneurysm.

Tests in arterial hypertension

In all patients with arterial hypertension, the following tests should be carried out:

- General analysis of blood and urine;
- The level of creatinine in the blood (to exclude kidney damage);
- The level of potassium in the blood without taking diuretics (a sharp decrease in the level of potassium is suspicious for the presence of an adrenal tumor or stenosis of the renal artery);
- Electrocardiogram (signs of left ventricular hypertrophy - evidence of a prolonged course of arterial hypertension);
- Determination of the level of glucose in the blood (on an empty stomach);
- The content in blood serum of total cholesterol, cholesterol of high and low density lipoproteins, triglycerides, uric acid;
- Echocardiography (determination of the degree of left ventricular myocardial hypertrophy and the state of cardiac contractility);
- Examination of the fundus.

Additional recommended studies:

- Chest x-ray;
- Ultrasound of the kidneys and adrenal glands;
- Ultrasound of the brachiocephalic and renal arteries;
- C-reactive protein in blood serum;
- Urine analysis for the presence of bacteria (bacteriuria), quantification of protein in urine (proteinuria);
- Determination of microalbumin in urine (mandatory in the presence of diabetes mellitus).
In-depth research:
- Assessment of the functional state of cerebral blood flow, myocardium, kidneys;
- Research in blood concentration of aldosterone, corticosteroids, renin activity;
- Determination of catecholamines and their metabolites in daily urine;
- Abdominal aortography;
- Computed tomography or magnetic resonance imaging of the adrenal glands and brain.

Treatment of arterial hypertension

The main goal of treating patients with arterial hypertension is to minimize the risk of developing cardiovascular complications and death from them. This is achieved through long-term life-long therapy aimed at:

- Decrease in blood pressure to normal levels (below 140/90 mm Hg). When arterial hypertension is combined with diabetes mellitus or kidney damage, a decrease in blood pressure <130/80 mm Hg is recommended (but not lower than 110/70 mm Hg);
- “Protection” of target organs (brain, heart, kidneys), preventing their further damage;
- Active influence on unfavorable risk factors (obesity, hyperlipidemia, disorders of carbohydrate metabolism, excessive salt intake, physical inactivity), contributing to the progression of arterial hypertension and the development of its complications.

Non-drug treatment of arterial hypertension

- Cessation of smoking;
- Normalization of body weight (body mass index <25 kg / m2);
- Reduction in consumption of alcoholic beverages <30 g of alcohol per day for men and 20 g/day for women;
- Increase in physical activity - regular physical activity for 30-40 minutes at least 4 times a week;
- Reduction of consumption of table salt to 5 g/day;
- A change in diet with an increase in the consumption of plant foods, a decrease in the consumption of vegetable fats, an increase in the diet of potassium, calcium contained in vegetables, fruits, grains, and magnesium contained in dairy products.

Basic principles of drug therapy for arterial hypertension:

Drug treatment should be started with the minimum doses of any class of antihypertensive drugs (taking into account the corresponding contraindications), gradually increasing the dose until a good therapeutic effect is achieved.

The choice of the drug must be justified, the antihypertensive drug must provide a stable effect during the day and be well tolerated by the patient.

It is most advisable to use long-acting drugs to achieve a 24-hour effect with a single dose. The use of such drugs provides a milder hypotensive effect with more intense protection of target organs.

With low efficacy of monotherapy (therapy with one drug), it is advisable to use optimal combinations of drugs to achieve the maximum hypotensive effect and minimal side effects.

Long-term (almost lifelong) medication should be taken to maintain optimal blood pressure and prevent complications of arterial hypertension.

Choosing the necessary medications:

Currently, seven classes of drugs are recommended for the treatment of arterial hypertension:

- Diuretics;
- Beta-blockers;
- Calcium antagonists (Felodipine);
- Angiotensin converting enzyme inhibitors;
- Angiotensin receptor blockers;
- Agonists of imidazoline receptors
- Alfa-blockers.

The indications for hospitalization of patients with arterial hypertension are:

- Unclear diagnosis and the need for special, often invasive, research methods to clarify the form of arterial hypertension;
- Difficulties in the selection of drug therapy - frequent hypertensive crises (a serious emergency caused by an excessive increase in blood pressure, manifesting clinically and requiring an immediate reduction in blood pressure levels to prevent or limit damage to target organs), refractory arterial hypertension.

Indications for emergency hospitalization:

- Hypertensive crisis that does not stop at the prehospital stage;
- Hypertensive crisis with severe manifestations of hypertensive encephalopathy (nausea, vomiting, confusion);
- Complications of hypertension requiring intensive therapy and constant medical supervision: cerebral stroke, subarachnoid hemorrhage, acute visual impairment, pulmonary edema, etc.

Post by: Emma Ager, MD, Copenhagen, Denmark