mechanism of the hypertension
disease (HD) is complex and includes the effect on blood pressure of many
factors. Of these three factors are considered as etiologic:
1) familial polygenic predisposition, and 2) external ENVIRONMENTAL
factors, and 3) adaptation factors 7. In accordance with one
of the most prominent hypotheses based on family history
is the so-called membrane defect, which manifests itself
violation ionotransportnoy function and stascture of plasma
cell membranes. These violations are responsible for increasing concentrations of
in the cytoplasm of free (ionized) calcium, and shift
plasmatic pH towards higher values, which changes
reactive cells, including vascular smooth muscle cells
wall. It also may change the sensitivity to NaCl,
broken tolerance to carbohydrates, hyperlipidemia occur,
hypeasricemia, exogenous obesity.
from environmental factors highlights
on psychological and social factors, low physical activity,
dietary disorders, especially excessive consumption of salt.
Adaptive Processes , occurring in response
to increased blood pressure, gives rise to stasctural changes
in the vascular wall, myocardium, changes in neurohumoral
regulation of the cardiovascular system. In particular,
stasctural changes are manifested thickening of arterial walls,
increased myocardial mass, vasoconstriction. The latter is
increase in the total vascular peripheral resistance and
accompanied by a decrease in circulating blood volume, which leads
to increase plasma renin levels. Superactivity
Renin stimulates the production of angiotensin, aldosterone.
Hypertension as a symptom of another disease
or condition may be caused by:
presence of elevated blood pressure associated with increased
the risk of stroke, coronary heart disease
, heart and kidney failure. The closest
correlation was detected between the indices of blood pressure and frequency
for stroke, as demonstrated by a significant increase
incidence proportion to the increase in BP. In particular,
ten years of observation showed that among the surveyed
aged 40-49 years and 50 - 59 years with diastolic BP 85-94 mm
Hg. Art. the incidence of stroke was 58-133 cases per 10 000
population, patients with mild hypertension - 124-259 cases, while diastolic
Blood pressure above 104 mm Hg. Art. incidence increased by 7 times
(406-765 per 10 000).
for the development of coronary artery disease in patients with hypertension of great importance
have other risk factors. For example, smoking and high levels of
cholesterol lead to increased mortality from coronary heart disease
10-15 times. As sharply deteriorating outlook of life in patients with
Hypertension with signs of destasction of target organs (heart,
brain, kidney, retinal artery, peripheral artery disease), frequency
identify which, according to the Framingham study, it is enough
high (Table 1).
Table 1
organ damage and risk factors for CHD
patients with hypertension
| Factors risk and disease | Frequency detection (%) |
| Smoking | 35 |
| Total cholesterol 5,17-6,21 mmol / lmorethan 6.21 mmol / L | 40-85 |
| and cholesterol (<0.9 mmol / l) | 25 |
| Obesity | 40 |
| Diabetes | 15 |
| Hyperinsulinemia | 50 |
| myocardial hypertrophy | 30 |
| Inactivity | 50 |
| hypeasricemia, proteinuria | 25-40 |
| CHD | 20 |
presence of coronary artery disease as organ damage in patients
with hypertension is recognized on the basis of clinical, electrocardiographic,
angiographic manifestations. The main method of identifying
myocardial hypertrophy is echocardiography,
as electrocardiographic method is less sensitive.
About lesions of the brain indicates the presence of
Dynamic cerebrovascular accidents or myocardial
stroke. Signs of peripheral arterial lesions are
significant weakening or absence of pulsations and the presence of
of aneurysmal expansion. The appearance of protein in urine, creatinine
Plasma 1, 5 mg% (133 umol / l) or microalbuminuria
indicate kidney failure . Normal kidneys can not produce
more than 200-300 mg of protein during the day. If you have nephrosclerosis
patients with hypertension protein excretion does not exceed 400 mg. Sharp increase
BP, especially in malignant hypertension, accompanied by high
proteinuria, which disappears after the reduction of blood pressure. Loss of more
2-3 grams of protein per day indicates that there is a patient of nephrotic
syndrome.
patients with hypokalemia (less than 3, 5 meq)
amount of the allocated 24 hours of potassium 50 mEq normal
consumption of salt (daily urinary sodium more
100 mg-eq) indicates the presence of hyperaldosteronism
(Primary or secondary).
haemorrhages, exudates and narrowing of retinal arteries
indicate the presence of II or stage III hypertension.
Experts from WHO and the International Society for the Study of
Hypertension offer depending on the level of blood pressure to allocate three
forms of hypertension: mild, moderate and high, as well as borderline
Blood pressure (hypertension or border) and isolated systolic hypertension (Table
2).
Table 2
Classification of BP (in mmHg. cent.) y
Adult
| Category | Systolic BP (mm Hg. Art.) | Diastolic BP (mm Hg. Art.) |
| Normal AG | <140 | <90 |
| Border AH | 140-160 | 90-94 |
| Soft AG | 161-180 | 95-104 |
| moderate hypertension | 181-210 | 105-114 |
| High AG | > 210 | 115 andmore |
| Systolic AH | ? 160 | <90 |
Depending on the presence or severity of
damage to target organs, the same group of experts selects
3 stages of hypertension. In patients with stage I-organ failure
not detected. For the diagnosis of stage II is required
at least one of the following criteria: 1) myocardial hypertrophy
left ventricle, and 2) the restriction of retinal artery, and 3) atherosclerotic
narrowing of large arteries, 4) protein in the urine or a moderate increase
creatinine in blood plasma 1, 2.2 mg% (106-177
umol / L). The third stage is characterized by the following
lesions of target organs: coronary artery disease, heart failure,
hypertensive encephalopathy or cerebral ischemia, increased
content of creatinine in blood plasma (> 2 mg%), renal
failure.
Compliance on the measurement of blood pressure is very important
to obtain reliable figures, it is recommended that:
1) Do not smoke or drink strong tea, coffee, at least for
half an hour before the measurement of blood pressure, and 2) for 1 h to avoid physical
loads, and are not used agonists (ephedrine
etc.), and 3) blood pressure measured at least twice. If the difference in
results greater than 5 mm Hg. Art., the measurement was repeated
until the results of the last two measurements are almost
differ, and 4) to measure up to 2 mm. For
This rate of decrease of pressure in the cuff of 2-3 mm / s
or 2 mm / one tone Korotkoff 5) the center of the cuff should be
over the ulnar artery, the lower edge - a 2-3 cm above the elbow
fossa, 6) cuff should fit snugly to the arm and pump
it should be up to the disappearance of the pulse at the radial artery.
control high blood pressure is provided by
nonpharmacological interventions and medications. The aim
control should be considered as reduction of blood pressure to 140/90 mm Hg. Art. and
perhaps less, especially in patients without myocardial ischemia and brain.
However, the question of to what level should reduce the blood pressure remains
unsolved.
non-pharmacological interventions include:
To reduce overweight is recommended
blood total cholesterol,
cholesterol in LDL and triglycerides,
and blockers?-adrenoceptors not only enhances the content
atherogenic lipid classes, but also reduce the amount of antiatherogenic
lipoproteins. Cancel them accompanied by a significant decrease in
caused by disturbances in lipid metabolism 10.
Diuretics and?-blockers and
contributing to the reduction in insulin sensitivity and increase
its content in the blood. Prolonged hyperinsulinemia provokes
hypertrophy of the muscle cells of the vascular wall and contributes
likely to atherogenesis 22.
blockers?-adrenoceptor negative
affect physical activity. In addition, these dasgs and
diuretics predispose to impotence.
calcium antagonists and ACE inhibitors is not
influence on the major risk factors. ACE inhibitors
even a moderate degree can increase sensitivity to insulin
and therefore indirectly may have a positive impact
the course of type II diabetes. There are reports that
dasgs from these groups inhibit the development of renal
and renal failure in hypertensive patients with diabetes
Diabetes 17.
Thus, when choosing dasgs for a long
therapy in patients with hypertension are currently important to consider not only
their hypotensive activity, but also their potential positive
effect on other risk factors for coronary heart disease or the appearance of
complications in the already suffering from CHD (Table 3).
testimony given in the table to select dasg
allow an individual approach to the choice of therapy
patients with hypertension. However, many patients monotherapy does not provide
sufficient hypotensive action. For example, captopril
at a dose of 100 mg / day only 25% of patients with stable elevated
BP reduces its level in the desired range (diastolic blood pressure
below 90 mm Hg. st). Monotherapy sympatholytic (clonidine, dopegit,
Rauwolfia dasgs) are generally not practical because of low efficiency,
provoking crisis course of the disease, a large number of side
reactions, reduced quality of life. It is therefore recommended to use
if necessary increase the hypotensive effects of other
dasgs in 3-4-th stage of combination therapy. To increase
effectiveness of ACE inhibitors is often resorted to the appointment
diuretics. In general, combination therapy involves the use of
dasgs belonging to different groups according to the mechanism of their antihypertensive
action.
Table 3
Determinants of individual choice
antihypertensive therapy
- subarohnoidalnoe hemorrhage
Sodium nitropassside, diazoxide, arfonad
- acute forms
? -Adreioblokatory, infusion of nitrates, sodium nitropassside
- pulmonary edema
furosemide, nitropassside, nitrates
- pulmonary edema
Furosemide, ganglioplegic
5) teach the patient self-measurement
BP.
In every conversation with a patient should be discussed
the next stage of treatment and the tasks that must be addressed.
This applies to life, weight control, other factors
CHD risk. The patient should be informed of the possibility of
not life-threatening side effects from taking dasgs,
in this case the patient must understand that the benefits of BP control is beyond doubt
and therefore the risk of such undesirable actions
has an excuse. In addition, it is also important to educate
work as a whole in Family hypertensive patients, taking into account
the importance of genetic factors in the development of this disease.
In conclusion, today, the question remains
the possibility of reducing mortality from coronary heart disease patients
with hypertension with calcium antagonists (especially the dihydropyridine group)
and ACE inhibitors. But thanks to the fact that verapamil and diltiazem,
as well as ACE inhibitors have a marked cardioprotective effect
and reduce mortality in CHD patients (respectively antagonists
calcium in patients without heart failure, and inhibitors
ACE-with heart failure and in patients with increased
volume of the left ventricle), at least half of whom suffer
AH, you can very likely to assume the possibility of
their positive influence on long-term outcome in patients with
Hypertension without coronary artery disease.
Dihydropyridine calcium antagonists group
because of the pronounced activating effect on the sympathoadrenal
system and a small effect on myocardial hypertrophy, probably
should not be used as monotherapy in patients with hypertension.
But in combination with sympatholytic, blockers?-Adrenoceptor
This group provides a good hypotensive effect and probably
has a cardioprotective effect. Monotherapy with these dasgs,
clearly shows only a small group of patients with bradycardia,
violation of the atrioventricular conduction, in which other
dasgs have contraindications to the use or have
pronounced side effects, or want to control other
diseases such as angina.
NA Mazur, Professor, Chair
Cardiology
PMA Postgraduate Education
Source: magazine "Medical Market",
¹ 23, c.7-14 .