Internal illnesses. Hypertension (lecture notes)

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Internal illnesses. Hypertension (lecture notes)

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LECTURE No. 3. Hypertension

A chronically occurring disease, the main manifestation of which is the syndrome of arterial hypertension, not associated with the presence of pathological processes in which an increase in blood pressure is due to known causes.

Etiology. The development of the disease is caused by neuropsychic overstrain and dysfunction of the gonads.

Pathogenesis. The biosynthesis of sympathetic amines is disrupted, resulting in an increase in the tone of the sympathoadrenal system. Against this background, the pressor mechanisms of the renin-angiotensin-aldosterone system are activated and the depressor factors are inhibited: prostaglandins A, E, and the kinin system.

Classification. In clinical settings, the disease is divided according to the severity of arterial hypertension, the degree of risk of developing damage to target organs, and the stage of development of hypertension.

Definition and classification of blood pressure levels

Normal BP:

1) optimal - less than 120 and less than 80 mm Hg. Art.;

2) normal - less than 130 and less than 85 mm Hg. Art.;

3) high normal - 130-139 and 85-89 mm Hg. Art.

Arterial hypertension:

I degree (soft) - 140-159 and 90-99 mm Hg. Art.;

subgroup: borderline - 140-149 and 90-94 mm Hg. Art.;

II degree (moderate) - 160-179 and 100-109 mm Hg. Art.;

III degree (severe) - more than 180 and more than 110 mm Hg. Art.

Hypertension isolated:

1) systolic - more than 140 and less than 90 mm Hg. Art.;

2) subgroup: borderline - 140-149 and less than 90 mm Hg. Art.

Definition of risk group

Table 1. Risk stratification

Note: FR - risk factors, POM - target organ damage, ACS - associated clinical conditions.

Table 2. Criteria for risk stratification

Risk levels (risk of stroke or myocardial infarction in the next 10 years): low risk (1) - less than 15%, medium risk (2) - 15-20%, high risk (3) - 20-30%, very high risk ( 4) - above 30%.

Determining the stage of hypertension:

Stage I: no changes in target organs;

Stage II: the presence of one or more changes in the target organs;

Stage III: the presence of one or more associated conditions.

Clinic. With hypertension stage I there are periodic headaches, tinnitus, sleep disturbance. Mental performance decreases, dizziness, nosebleeds are noted. Possible cardialgia.

In the left thoracic branches, the presence of high-amplitude and symmetrical T waves is possible, the minute volume of the heart remains normal, increasing only during exercise. Hypertension crises develop as an exception.

With stage II hypertension there are frequent headaches, dizziness, shortness of breath during physical exertion, sometimes angina attacks. Possible nocturia, the development of hypertensive crises.

The left border of the heart shifts to the left, at the top of the first tone is weakened, an accent of the second tone is heard over the aorta, sometimes a pendulum-shaped rhythm. Cardiac output at rest is normal or slightly reduced, with dosed physical activity it increases to a lesser extent than in healthy individuals, the speed of propagation of the pulse wave is increased.

With stage III hypertension two options are possible:

1) there is a development of vascular accidents in target organs;

2) there is a significant decrease in minute and stroke volumes of the heart at a high level of peripheral resistance, the load on the left ventricle decreases.

With malignant hypertension extremely high blood pressure figures are noted (diastolic blood pressure exceeds 120 mm Hg), leading to the development of pronounced changes in the vascular wall, tissue ischemia and impaired organ functions. Renal failure progresses, vision decreases, weight loss, symptoms from the central nervous system, changes in the rheological properties of the blood appear.

Hypertensive crises

Sudden sharp increase in blood pressure. Crises are of two types.

Crisis type I (hyperkinetic) is short-lived. It develops against the background of good health, lasts from several minutes to several hours. Manifested by a sharp headache, dizziness, blurred vision, nausea, rarely vomiting. Excitation, palpitation and trembling throughout the body, pollakiuria are characteristic, by the end of the crisis there is polyuria or copious loose stools. Systolic blood pressure rises, pulse pressure rises. It is necessary to immediately lower blood pressure (not necessarily to normal).

Type II crisis (eu- and hypokinetic) is severe. It develops gradually, lasts from several hours to 4-5 days or more. Caused by circulatory hypoxia of the brain, characteristic of the later stages of hypertension. Manifested by heaviness in the head, severe headaches, sometimes paresthesia, focal disorders of cerebral circulation, aphasia. There may be pain in the heart of an anginal nature, vomiting, attacks of cardiac asthma. Significantly increased diastolic pressure. Blood pressure should be reduced gradually over several hours.

Additional diagnostic study. The examination includes 2 stages: a mandatory study and a study to assess target organ damage.

Mandatory studies include: a general blood and urine test, determination of potassium, fasting glucose, creatinine, total blood cholesterol, electrocardiography, chest x-ray, fundus examination, ultrasound examination of the abdominal organs.

Additional studies include: echocardiography (as the most accurate method for diagnosing left ventricular hypertrophy), ultrasound examination of peripheral vessels, determination of the lipid spectrum and triglyceride levels.

Complications. The development of hemorrhagic stroke, heart failure, grade III-IV retinopathy, nephrosclerosis (chronic renal failure), angina pectoris, myocardial infarction, atherosclerotic cardiosclerosis is possible.

Differential diagnostics. It is carried out with secondary hypertension: diseases of the kidneys, adrenal glands (Itsenko-Cushing syndrome, Conn syndrome), pheochromocytoma, Itsenko-Cushing disease, organic lesions of the nervous system, hemodynamic arterial hypertension (aortic coarctation, aortic valve insufficiency, sleep-disordered breathing syndrome), iatrogenic arterial hypertension.

Treatment. At high and very high risk levels, immediate medication is prescribed. If the patient is classified as an average risk group, the question of treatment is decided by the doctor. Observation with blood pressure control is possible from several weeks to 3-6 months. Drug therapy should be prescribed if blood pressure remains above 140/90 mm Hg. Art. In the low-risk group, longer observation is possible - up to 6-12 months. Drug therapy is prescribed when blood pressure levels remain above 150/95 mm Hg. Art.

Non-drug treatments include smoking cessation, weight loss, alcohol restriction (less than 30 g per day for men and 20 g for women), increased physical activity, and reduction of salt intake to 5 g per day. A comprehensive change in diet should be carried out: it is recommended to eat plant foods, reduce fat, increase potassium, calcium contained in vegetables, fruits and grains, and magnesium contained in dairy products.

Drug treatment is carried out by the main groups of drugs:

1) the central mechanism of action: central sympatholytics, imidazoline receptor agonists;

2) antiadrenergic, acting on adrenergic receptors of various localization: ganglionic blockers, postganglionic adrenergic blockers, non-selective α-adrenergic blockers, selective α₁-blockers, β-blockers, α- and β-blockers;

3) peripheral vasodilators: arterial myotropic action, calcium antagonists, mixed, potassium channel activators, prostaglandin E₂ (prostenon);

4) diuretics: thiazide and thiazide-like, potassium-sparing;

5) ACE inhibitors (angiotheisin converting enzyme inhibitors);

6) neutral endopeptidase inhibitors;

7) angiotensin II (AII) receptor antagonists.

Antihypertensive drugs of the 1st line include ACE inhibitors, β-blockers, diuretic drugs, calcium antagonists, AII receptor antagonists, α-blockers.

Effective drug combinations:

1) diuretic and β-blocker;

2) a diuretic and an ACE inhibitor or an angiotensin II receptor antagonist;

3) a calcium antagonist from the group of dihydropyridones and a β-blocker;

4) calcium antagonist and ACE inhibitor;

5) α-blocker and β-blocker;

6) a drug of central action and a diuretic. In uncomplicated hypertensive crisis, treatment can be carried out on an outpatient basis, oral β-blockers, calcium antagonists (nifedipine), clonidine, short-acting ACE inhibitors, loop diuretics, prazosin are prescribed.

With a complicated hypertensive crisis, vasodilators (sodium nitroprusside, nitroglycerin, enaprilat), antiadrenergic drugs (phentolamine), diuretics (furosemide), ganglioblockers (pentamine), antipsychotics (droperidol) are administered parenterally.

Flow. The course is long, with periods of remission; progression depends on the frequency and nature of exacerbations, the duration of periods of remission.

Forecast. The prognosis of the disease is determined by the stage of its course. At stage I - favorable, at stages II-III - serious.

Prevention. Prevention of the disease should be aimed at treating patients with neurocirculatory dystonia, monitoring those at risk, and using active recreation. When a diagnosis of hypertension is made, continuous comprehensive treatment is carried out.

Author: Myshkina A.A.

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