Transcript 07_Main symptoms and syndromes in arterial hypertension

Main symptoms and
syndromes in
arterial hypertension
N. Bilkevych
Arterial hypertension is defined as
rising of arterial blood pressure
excess of 140 mm Hg systolic one
(SBP), and/or excess of 90 mm Hg
diastolic blood pressure (DBP).
Поширеність основних серцевосудинних захворювань в Україні
16%
28%
15%
41%
ЦВЗ - цереброваскулярні захворювання
ІХС - ішемічна хвороба серця
ГХ - гіпертонічна хвороба
Epidemiology
 Hypertension is one among the most widespread among all cardiovascular diseases.
 15 – 25 % of people in the population have
hypertension + 15 % have bordeline
hypertension.
 Primary hypertension occupies 80 – 95 %
of all arterial hypertensions and 10 % of
them are secondary hypertensions.
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Mortality because of AH according to
its degree
Presentation of AH in the population
according to usage of fats in the diet
Essential, primary, or idiopathic
hypertension is defined as high BP in
which secondary causes forms are not
present
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Aetiology and pathogenesis:
Overstrain of the central nervous system
nervous-functional disorder in regulation of the
vascular tone
vegetative-endocrine disorders and changes in
the renal regulation of the vascular tone
vasopressor adrenal reaction by which arterioles
of internal organs are narrowed
production of rennin, stimulation of renninangiotensin system and systemic vasodilatation
activation of aldosterone secretion.
Pathogenesis
of AH
Risk-factors
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Non-modified
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Age
Genetics and family history
Sex( male or female)
Family and personal history of hyperlipidaemia
Family and personal history of diabetes
Race
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Modified
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Cigarette smoking, alkohol
Environment (stress, sedentary lifestyle)
Weight (obesity and metabolic syndrome)
Dietary habits (high alcohol intake, high sodium intake, low
potassium intake)
Hypodinamia
Personality
Classification
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According to blood
pressure:
- normal: SBP < 130
and DBP < 90 mm of
Hg.
Bordeline
hypertension: SBP =
140-160 and DBP =
90-95 mm of Hg;
- Arterial
hypertension: SBP >
160 and DBP > 95
mm of Hg.
SBP
DBP
Optimal
<120
<80
Normal
<130
<85
High
normal
130-139
85-89
Hyperten
sion
I (mild)
140-159
90-99
II(moderat
e)
160-179
100-109
III (severe) >180
>110
Isolated
systolic
<90
>140
Level of BP in mild, moderate and
severe AH
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WHPO classification of arterial hypertension
(1993)
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Stage I – no evident signs of target organ damage
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Stage II – presence of at least one of the following
signs of target organ damage:
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Heart: LVH (diagnosed radiologically, on ECG or by Echocardiography)
Retina: generalized or focal narrowing of retinal arteries
Kidney: microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l)
Vessels: increased IMT or plaques in carotid, iliac, or femoral arteries
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Stage III – signs of severe target organ damage:
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Heart: angina pectoris, myocardial infarction, heart failure
Brain: stroke, TIA, vascular dementia
Retina: haemorrhages, exudates, papilloedema
Kidney: renal insufficiency (creatinine>2mg/ml)
Vessels: dissecting aortic aneurysm, symptomatic occlusive peripheral arterial
disease
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Clinical manifestation
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Manifestation of
hypertension depends
on:
Course of the disease
Its stage;
Presence of
complications and
crises;
Pathogenetic variant
(benign and maligant).
The main objective sign
of the disease is elevated
arterial pressure (over
140/90 mm Hg) . Blood
pressure is liable in early
stage of the disease but
later stabilizes.
I stage
Complaints:
 may be abcent
 patients would usually complain of neurotic disorders:
general weakness, impaired work capacity, inability to
concentrate during work, deranged sleep, trancient
headache, e feeling of heaviness in the heart, vertigo,
noise in the ears, and sometimes palpitation, hain in
heart region. Exertional dyspnoea develops later.
Data of objective examination
 Signs if lesions of internal organs are abcent
 Stable or trancient elevation of BP
II stage
Complaints
 headache
 Dizziness
 Pain in heart region
 Exertional dyspnoea
 Presence of hpertonic crises
 Data of obyective examination : rddness of skin, sweating, decreased tolerance
to physical load.
 Palpation: Ps – firm and tense, fast. Apex beat is expanded and displaced leftward
and downward.
 Percussion: widened vascular bundle, displacement of the left border of relative
cardiac dullness.
 Auscultation: The second heart sound is accentuated over the aorta. Systolic
murmur over heart apex
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There are signs of internal ograns without functional disorders:
Hypertrophty of the left ventricle (according to data of ECG and X-ray, ultrasound
examination).
Generalized or focal narrowing of retinal vessels.
Microalbumiuria, proteinuria and/ormild elevation of blood plasma creatinin (up to
177 mkm/l).
III stage
High, stable elevation of BP
 Development of complications:
- Myocardial infarction
- Heart failure
- Insult
- Trancient ischemic attack
- Retinal hemorrhage
- Dissecting aortic aneurism
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ECG
І st. – specific signs are abcent.
 ІІ – ІІІ st . – hypertrophy of the left
ventricle, heart electrical axis is
deviated leftward,
Rv5-6>Rv4, elevation of ST, biphasic Т
(+-)
Increased amplitude of R in left leads
and S - in right leads.
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ECG in hypertrophy of the left ventricle
Ultrasoung examination of hypertensive heart (B- and Mmodes)
Left-ventricular hypretrophy on X-ray
Symptoms of organs damage
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Heart: palpitations, chest pain, shortness of breath, swollen ankles
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Brain and eyes: headaches, vertigo, impaired vision, TIA’s, sensory or motor deficit
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Kidney: thirst, polyuria, nocturia, haematuria
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Peripheral arteries: cold extremities, intermittent claudication
Brain: murmurs over neck arteries, motor or sensory deficits
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Eyes: funduscopic abnormalities
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Heart: location and characteristics of apical impulse, abnormal cardiac rhythms,
ventricular gallop, pulmonary rales, peripheral oedema
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Peripheral arteries: absence, reduction, or asymmetry of pulses, cold extremities,
ischaemic skin lesions
Complications
Дослідження очного дна
HYPERTENSIVE RETINOPATHY
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I degree: Arteriolar
thickening, tortuosity and
increased reflectiveness
('silver wiring') II degree:
plus constriction of veins
at arterial crossings
('arteriovenous nipping')
III degree: plus evidence
of retinal ischaemia
(flame-shaped or blot
haemorrhages and 'cotton
wool' exudates) IV degree:
plus papilloedema
Hypertensive retinopaty
The excess cardiac
mortality and
morbidity associated
with
 Hypertension. Severe
hypertension can
cause left ventricular
failure in the absence
of coronary artery
disease
 Atrial fibrillation
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Heart
Secondary hypertension
CAUSES OF SECONDARY HYPERTENSION
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Alcohol
Pregnancy (pre-eclampsia)
Renal disease
• Renal vascular disease
• Parenchymal renal disease,
particularly glomerulonephritis
• Polycystic kidney disease
Endocrine disease
Phaeochromocytoma
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Cushing's syndrome
Primary hyperaldosteronism
(Conn's syndrome)
Hyperparathyroidism
Acromegaly
Primary hypothyroidism
Thyrotoxicosis
Congenital adrenal hyperplasia
due to 11 -p-hydroxylase or
17-hydroxylase deficiency
Differential features of symptomatic
hypertension
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Age less than 20 years or more than 60;
quick elevation of BP and its stable high level
very high BP (> 220/120 mm of Hg);
- malignant course of hypertension;
- sympathoadrenal crisesеs;
- renal diseases in anamnesis;
development
of
hypertension
during
pregnancy;
- appearance of changes in patient’s urine.
Complications of hypertonic crisis
Cardial:
- acute or chronic heart failure;
- accelerated development of atherosclerosis of
caoronary arteries followed by symptoms of
angina pectoris and myocardial infarction;
- arrhythmias.
 Aortal:
- atherosclerosis ;
- dissecting aortal aneurism.
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Cerebral:
- atherosclerosis of
cerebral vessels and
impaired cerebral
circulation
(encephalopathy);
- dynamic and organic
disorders of brain
circulation і органічні
Ocular:
- retinal hemorrhage and
its separation;
- decreased vision (edema
of ophthalmic nerve).
Treatment
Modification of life-style
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Diet (Decreased salt intake to
4-6 g/day, alkohol, animal
fats).
Decreased body weight.
Avoiding of smoking.
Dynamical physical
examinations.
Phytotherapy, acopuncture,
psychtherapy, authotrening
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Influence of modification of
life-style of the course of the
disease:
Decreased body weight - 5-20
mm of Hg/10 kg of lost weight
Diet – 8-14 mm of Hg
Decreased salt intake (6 g per
day) – 2-8 mm of Hg
Physical activity (30 min per
day) – 4-9 mm of Hg
Decreased alkohol
consumption (to 1 ounce per
day) – 2-4 mm of Hg
Scheme of action of hypotensive
drugs
Main groups of hypertensive drugs
Diuretics
 -blockers
 Ca- channels antagonists
 Angiotensine-converting enzyme inhibitors
 Blockers of angiotensine-II receptors
 ά1-adrenoblochers
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TARGET <140 mm Hg systolic and < 90 mmHg diastolic
Lifestyle modification
therapy
Thiazide
diuretic
ACE-I
ARB
Long-acting
CCB
Dual Combination
Triple or Quadruple
Therapy
* Not indicated as first line therapy over 60
Betablocker*