19Feb

Hypertensive disease: WHO definition and diagnosis

Before the diagnosis of "Hypertonic Disease", as in the diagnosis of any other disease, a number of general and laboratory studies are conducted, the lifestyle of the patient is also assessed, and the presence of risk factors is checked. It should be remembered that hypertension( arterial hypertension) is a multifactorial disease provoked by a genetic structural defect.

Arterial hypertension and hypertension are the same?

To begin with it is necessary to understand, arterial hypertension and hypertension are the same, or are these two different ailments? In the Russian Federation, as in the whole world, arterial hypertension( hypertension, hypertension and hypertension hypertension are synonyms and mean increased pressure) remains one of the most pressing problems in cardiology. This is due to the fact that hypertension( arterial hypertension), which in many respects determines the high cardiovascular morbidity and mortality, is characterized by a wide prevalence and, at the same time, the lack of adequate control at the scale of the population. Even in countries with a high level of organization of healthcare, this indicator today does not exceed 25-27%, while in Russia only 5.7% of men and 17.5% of women are adequately controlled by blood pressure( BP).

In the definition of hypertension, this term, proposed by GF Lang, corresponds to the term "essential hypertension( hypertension)" used in other countries. Under GB it is customary to understand a chronic course of the disease, the main manifestation of which is the syndrome of arterial hypertension, not associated with the presence of pathological processes, in which the increase in blood pressure is due to known causes( symptomatic arterial hypertension).

Diagnosis of hypertension and examination of patients with AH is carried out in strict sequence, responding to certain tasks:

  • determination of the stability of BP increase and its degree;
  • elimination of symptomatic hypertension or identification of its form;
  • Identification of the presence of other risk factors for cardiovascular diseases and clinical conditions that may affect prognosis and treatment, as well as referring the patient to a particular risk group;
  • detection of lesions of "target organs" and assessment of their severity.

Guidelines for measuring blood pressure on arms and legs with

cuff Hypertensive disease, as defined by WHO and MOG( World Health Organization and International Society of Hypertension), is a condition in which systolic blood pressure is 140 mm Hg. Art.or higher and a diastolic blood pressure of 90 mm Hg. Art.or higher in persons not receiving antihypertensive therapy.

Compliance with the rules for measuring blood pressure is necessary for the correct diagnosis and the degree of hypertension.

When detecting hypertension for measuring blood pressure, it is important to observe the following conditions:

  • Patient's position: sitting in a comfortable posture;hand on the table. The cuff is placed on the shoulder at the level of the heart, the lower edge of it is 2 cm above the elbow fold.
  • Circumstances: the use of coffee and strong tea is excluded for 1 hour before the examination;do not smoke for 30 minutes. The use of sympathomimetics, including nasal and eye drops, is excluded.
  • Measurement is carried out at rest after a 5-minute rest. If the BP measurement procedure was preceded by a significant physical or emotional load, the rest period should be extended to 15-30 minutes.

It is necessary to select the appropriate cuff size for measuring blood pressure( the rubber part must be at least 2/3 of the length of the forearm and not less than 3/4 of the arm circumference).The mercury column or the arrow of the blood pressure monitor must be at zero before starting the measurement.

Multiplicity of measurement. To assess the level of blood pressure on each arm should be performed at least three measurements with an interval of at least 1 minute, with a difference of 8 or more mm Hg. Art.2 additional measurements are made. The final( registered) value is taken as the average of the last two measurements. To diagnose the disease must be carried out at least 2 measurements with a difference of at least a week.

Actual measurement. Rapidly inflate the air into the cuff to a pressure level of 20 mm Hg. Art.exceeding the systolic( from the disappearance of the pulse).The blood pressure is measured to within 2 mm Hg. Art. Reduce the pressure in the cuff by 2-3 mm Hg. Art.in 1 second. The level of pressure at which the first tone appears corresponds to systolic blood pressure( the first phase of Korotkov's tones).The pressure level at which the disappearance of tones occurs( the 5th phase of Korotkov's tones) is taken as the diastolic pressure. In children and some pathological conditions in adults it is impossible to determine the 5th phase, then we should try to determine the fourth phase of Korotkov's tones, which is characterized by a significant weakening of tones. If the tones are very weak, you should raise your hand and perform several compressive movements with a brush;then repeat the measurement. Do not strongly squeeze the artery with a phonendoscope membrane. At the initial examination of the patient, the pressure on both hands should be measured. In the future, measurements are taken on the arm where the BP is higher. In patients older than 65 years, patients with diabetes mellitus and receiving antihypertensive therapy should also make a measurement of blood pressure standing in 2 minutes. It is also advisable to measure blood pressure on the legs, especially in patients younger than 30 years. Measurement of blood pressure on the legs is desirable to be carried out using a wide cuff( the same as for obese individuals), the phonendoscope is located in the popliteal fossa.

Self-monitoring of blood pressure by a patient or his relatives with the help of automatic and semi-automatic devices can be extremely useful in achieving adequate treatment of hypertension and is an integral part of educational programs.

24-hour blood pressure monitoring for hypertension

24-hour blood pressure data are of greater predictive value than single measurements. The recommended daily monitoring program for blood pressure involves recording BP at intervals of 15 minutes during wakefulness and 30 minutes during sleep. The absence of a nightly decrease in blood pressure or the presence of excessive reduction of blood pressure should attract the attention of the doctor, since such conditions increase the risk of organ damage.

Having unconditional informativeness, daily monitoring of arterial pressure today is not universally accepted due to its high cost. After identifying a stable hypertension, a patient should be examined for symptomatic types of hypertension. Further, the degree and stage of the disease, as well as the degree of risk, are determined.

Lifestyle assessment in hypertensive disease

At the first stage of the examination for the detection of hypertension, compulsory studies are conducted. This stage includes the detection of damage to "target organs," the diagnosis of concomitant clinical conditions affecting the risk of cardiovascular complications, and the classical methods of diagnosing secondary hypertension.

Lifestyle assessment in the detection of hypertension includes:

  • consumption of fatty foods, table salt, alcoholic beverages;
  • quantitative assessment of physical activity, as well as data on changes in body weight in the first year of life;
  • personality and psychological characteristics;
  • environmental factors that could affect the course and outcome of the treatment of hypertension, including marital status, work situation, educational level.

Anamnesis of a patient with hypertensive disease

In a patient with a newly diagnosed hypertensive disease, the anamnesis should include: the duration of the existence of hypertension and the levels of blood pressure increase in the anamnesis, as well as the results of previous antihypertensive treatment, the presence of hypertensive crises in the history;data on the presence of symptoms of heart failure, coronary artery disease, central nervous system diseases, peripheral vascular lesions, diabetes mellitus, gout, lipid metabolism disorders, bronchial obstructive diseases, kidney diseases, sexual disorders and other pathologies, as well as information on medications used for treatmentthese diseases, especially those that can contribute to high blood pressure.

In women with hypertensive disease, a gynecological anamnesis is important, the connection of increasing blood pressure with pregnancy, menopause, hormonal contraceptive use, hormone replacement therapy.

If you suspect a hypertensive disease, a family history is important in terms of the cases of diagnosed hypertension, diabetes mellitus, lipid metabolism disorders, stroke, kidney diseases in close relatives.

Objective and laboratory studies of hypertensive disease

In an objective study of essential hypertension, the following are mandatory:

  • weight measurement with the calculation of the body mass index( weight in kilograms divided by the square of growth in meters);
  • assessment of the state of the cardiovascular system: the size of the heart, the presence of pathological noise, heart failure( wheezing in the lungs, swelling, liver size, pulse detection on peripheral arteries);
  • revealing pathological noise in the projection of the renal arteries;
  • assessment of kidney condition;
  • revealing volumetric neoplasms.

Laboratory and instrumental studies are conducted in two stages.

First stage:

  • blood and urine analysis;
  • potassium;
  • fasting glucose;
  • creatinine;
  • total blood cholesterol;
  • ECG;
  • chest X-ray;
  • examination of the fundus;
  • ultrasound of the abdominal cavity.

If at this stage of the examination the doctor does not have any grounds confirming the secondary nature of hypertension, and the available data is sufficient to determine the risk group for hypertension of the patient and, accordingly, the tactics of treatment, this can be completed.

The second stage involves research to clarify the form of symptomatic hypertension, additional survey methods to assess the extent of damage to "target organs," identifying additional risk factors.

Surveys for the detection of secondary hypertension

If suspected of secondary hypertension, targeted studies are performed to clarify its form and, in some cases, the nature and / or location of the pathological process.

For clarification in case of suspected atherosclerosis of the renal artery, it is necessary to perform: fusional renography, renal scintigraphy, Doppler blood flow in renal vessels, aortography, separate determination for renal veins catheterization.

For possible parenchymal lesions of the kidneys, is a Reberg sample, daily protein loss, urine culture, kidney biopsy.

Primary hyperaldosteronism( Conn's syndrome) requires: to determine the level of aldosterone and plasma renin activity, computed tomography of the adrenal gland, MRI.Also for the detection of secondary arterial hypertension in this case it is necessary to take samples with hypothiazide and veroshpiron.

Syndrome or Cushing's Disease: Cortisol level in the blood;excretion of oxycorticosteroids with urine;a test with dexamethasone;visualization of the adrenal glands and pituitary gland( ultrasound, computed tomography, MRI).

Pheochromocytoma and other chromaffin tumors: determination of the level of catecholamines and their metabolites in blood and urine;visualization of a tumor( CT, ultrasound, scintigraphy, MRI).

Insufficiency of aortic valves: ECHO.

Syndrome of respiratory failure in sleep - polysomnography.

Additional studies to assess concomitant risk factors and target organ damage are performed when they can affect the management of the patient, i.e. their results may lead to a change in the level of risk. This is ultrasound of the kidneys and peripheral vessels;echocardiography as the most accurate method of diagnosis.

Classification of arterial hypertension in degrees

The classification of blood pressure levels in adults over 18 years of age is presented in the table below. The term "degree of arterial hypertension" is preferable to the term "stage", since the word "stage" implies progression over time.

Degree classification of arterial hypertension:

Category

AD

AD

systolic( mmHg)

diastolic( mmHg)

Optimal

& lt;120

& lt; 80

Normal

& lt;130

& lt; 85

High normal

130-139

85-89

AG

140-159

90-99

AG of the second degree

160-179

100-109

AG of the third degree

& gt;180

& gt; 110

Isolated systolic hypertension

& gt;140

& lt; 90

If the systolic or diastolic BP value falls into different categories, a higher category is established.

The degree of hypertension is established in cases of newly diagnosed AH and in patients not receiving antihypertensive drugs.

Risk factors for the development of arterial hypertension

In patients with AH, the prognosis depends not only on the level of blood pressure. The presence of concomitant risk factors for the development of arterial hypertension, involvement in the process of "target organs", as well as the presence of associated clinical conditions are no less important than the degree of increase in blood pressure, in connection with which the modern classification introduced stratification of patients depending on the degree of risk.

The decision on the nature of management of a patient with hypertension should be taken not only on the basis of blood pressure level. It is also necessary to consider the presence of other risk factors for hypertension and related diseases, such as diabetes, the pathology of "target organs," cardiovascular and renal lesions. It is also necessary to take into account some aspects of the patient's personal, clinical and social status.

To assess the total effect of several risk factors for arterial hypertension relative to the absolute risk of severe cardiovascular lesions, WHO experts have proposed systematizing risk in four categories( low, medium, high and very high risk).The risk factors for the development of hypertension in each category are calculated on the basis of data on the risk of death from cardiovascular diseases averaged over 10 years, the risk of stroke and myocardial infarction( according to the results of the so-called Framingham study).

Table of distribution of groups of arterial hypertension by degree of risk

Table of distribution of hypertension by degree of risk:

Risk factors and medical history

Blood pressure( mmHg)

Degree 1( mild AG) 140-159 / 90-99

Degree II( moderate hypertension) 160-179 / 100-109

Degree III( severe AH)systolic BP & gt;180 or diastolic> 110

1. No RF, POM, ACS

Low risk

Mean risk

High risk of

2. 1-2 risk factors( except DM)

Average risk

Average risk

Very high risk

3. 3and more than FF and / or POM and / or SD

High risk of

High risk of

Very high risk of

4. AKS

Very high risk of

Very high risk of

Very high risk of

In the table of distribution of groups of arterial hypertension in terms of risk, the followingabbreviations:

  • FR - Factors rika;
  • POM - defeat of "target organs";
  • AKS - associated clinical conditions.

Risk levels( risk of stroke or myocardial infarction in the next 10 years): low risk( 1) - less than 15%, average risk( 2) - 15-20%, high risk( 3) - 20-30%, very high risk4) - 50% or higher.

Etiology and pathogenesis of arterial hypertension

Etiology and pathogenesis of arterial hypertension are associated with increased release of adrenaline, angiotensin, impaired excitatory processes.

Arterial hypertension is a multifactorial disease, which is based on a genetic structural defect, which determines the high activity of long-acting pressor mechanisms.

The arterial hypertension as a risk factor for diseases has been fixed since the depletion of the depressor function of the kidneys. The disease manifests itself as a persistent chronic increase in systolic or diastolic pressure and is characterized by a statistical frequency of development of 15 to 45% of the adult population.

Thus, all cases of persistent chronic hypertension, in which a genetic defect is considered to be characteristic of hypertensive disease, refers to the so-called essential hypertension.

Along with this, there is also a variant of reversible( acute) arterial hypertension, which can occur when the organs involved in the regulation of blood pressure are affected.

So, it is possible to increase blood pressure in diseases of the kidneys, adrenals and other endocrine organs with a genetically complete system of hemodynamic regulation. In such cases, termination of the pathological process in these organs will result in normalization of the pressure.

Hypertension, which develops in chronic renal failure, stands apart. In this case, the disease will be persistent and chronic due to severe nephrosclerosis, leading to a persistent loss of physiological function of the kidneys.

The basis of persistent chronic hypertension is very often the hereditary polygenetic genetic defect, manifested by a number of structural changes( known - changes in cell membranes) and triggering mechanism that causes vasoconstriction along with sodium retention. Activation of the pressor cycle, in turn, activates the depressor system of prostaglandins.

Some time these systems can be in balance, but after the exhaustion of compensation mechanisms, hypertension is consolidated.

In 2002, another alternative system of depressor angiotensin was discovered. In general, this system functions as follows. Under the influence of renin, produced by the kidneys, a new substrate is formed from angiotensinogen, which is important in the development of hypertension, - but so far the real comprehension of this factor is not yet completely clear and requires time for further study.

Thus, as a primary hypertension, the form of genetically determined persistent chronic arterial hypertension( hypertensive disease, essential hypertension) is considered.

Risk factors for its fixation( accelerating factors) - excessive consumption of table salt, kidney disease, adrenal gland, renal arteries. The fixation of elevated blood pressure is realized through an increase in the total peripheral vascular resistance, an increase in cardiac output, and the volume of freely circulating blood.