IFNMU Cafedra of propedeutics of internal medicine

The chairman – professor V. Y. Neiko

Lecture

The lecture prepared by docent Iryna Gayova

The main symptoms and syndromes at arterial hypertensions

Definition

Arterial hypertension – is an increased systolic blood pressure (140 mm Hg and more) and (or) diastolic blood pressure (90 mm Hg and over 90)

Complains of the patients

• Headache• Dizziness• Noisea• Noise in the ears• Disorders of sight• Sometimes – pain in the heart• Dispnea at physical exercises• Irritation• Poor night sleep

At examination

• Palpation: the apex beat is increased, often shifted laterally and down

• Percussion: left border of the relative dullness is shifted to the left

• Auscultation of the heart: accent of the II tone over aortal valve (the II intercostal space, right edge of sternum)

• Pulse intensive and hard• High arterial blood pressure (140/90 mmHg and

more)

X-Ray examination

• Left ventricular hypertrophy

ECG-examination

• The electrical axis of the heart is shifted to the left

• The ECG-signs of left-ventricular hypertrophy

• The signs of chronic coronary insufficiency (ischemia)

EchoCG

• Dilatation of left atrium

• Hypertrophy of left ventricle

• The signs of diastolic left ventricular disfunction

• Dilatation of left ventricle

On the retina

• The arteries are narrowed, the veins are dilated (Salus’ symptom)

• In the places of the vessels crossing – the illusion of the “ruptured” veins (actually they are not ruptured) the veins are overload with blood

• The arterial wall are in spasm and thick – the symptom of a “copper wire” (at the beginning)

• At severe sclerosis – the arterias become white, shining (the symptom of a ”silver wire”)

Renal symptoms

• The result of disorder of blood circulation in kidneys – albuminuria, the single erythrocites in urine

• Later the chronic renal insufficiency occurs – which is detected by isohypostenuria and polyuria

Classification of arterial hypertension accordingly the levels of blood

pressure Normotension: systolic BP / diastolic BP

• Optimal BP <120 mmHg / <80 mmHg

• Normal BP <130 mmHg / <85 mmHg

• The high normal BP

130 - 139 mmHg / 85-89 mmHg

Hypertension

The I stage (mild) hypertension

140-159 mm Hg (systolic) / 90-99 mmHg (diastolic)

The II stage (moderate)

160-179 mm Hg / 100 – 109 mm Hg

The III stage (hard)

≥ 180 mm Hg / ≥ 110 mm Hg

Isolated systolic hypertension

>140 mm Hg / < 90 mm Hg

The names “essential” hypertension and hypertensive disease

• Hypertension is defined essential if it’s reason can not be detected

• The synonim for essential hypertension is – hypertensive disease

Classification accordingly the damage of the target-organs

• The I stage – the objective signs of the damage of the target organs are absent

• The II stage – the objective signs of the damage of the target organs are present:

- left ventricular hypertrophy (ECG, EchoCG, X-Ray)• general narrowing of the retinal arteries• microglobulinuria or proteinuria or increased level of creatinin in plasma(up to 177 mcmol/l)

Classification accordingly the damage of the target-organs

• The III stage - the objective signs of the damage of the target organs are present and their function is broken (on the background of the long-termed arterial hypertension)-

• Heart – myocardial infarction, cardiac failure II-A - III

• Brain – stroke, encephalopathy, vascular demention

• Retina – hemorrhages and exudates into retina with edema of the discus of nervus opticus

Classification accordingly the damage of the target-organs

- Kidneys -increased level of creatinin in plasma (>177 mcmol/l)

- Vessels – dissectional aneurism of aorta

Classification of the secondary (symptomatical) hypertension

• Nephrogenic : 1. Renovascular (at stenosis of a.renalis) 2. Chronic pyelonephritis, interstitial nephritis, hydronephros, stones in kidneys 3. Glomerulonephritis, nephrosclerosis 4. The renal damage on the background of tuberculosis,

tumor, sepsis, diffusal diseases of connective tissue 5. Inherited renal anomalies – cystes, hypoplasia6. At diabetus – nephropathy, Kimmelstil-Wilson’s

syndrome, amyloidosis7. Hormonal reninoma

Classification of the secondary (symptomatical) hypertension

• Endocrynal: 1. Hyperaldosteronism: a)primary (Konn’s syndrome) -

aldosteron-secreting tumor of the suprarenal cortexb) pseudoprimary – idiopathyc hyperplasia of the

suprarenal cortexc) corticosteroid-depending2. Itsenko-Kushing’s syndrome3. Pheochromocytoma, pheochromoblastoma,

paraganglioma4. Acromegalia

Classification of the secondary (symptomatical) hypertension

• Hemodynamic (cardiovascular):1. Atherosclerosis, aortal valve’s insufficiency,

bradycardia, complete AV blockade (mostly systolic)

2. Coarctation of aorta3. Ischemic and congenital, at ischemic heart

disease, mitral defect4. Erythremia, rheologic disorders of blood5. Hypercinetic syndrome, hyperthyreosis, anemia

Classification of the secondary (symptomatical) hypertension

• Neurogenic:• 1. Tumor of brain and vascular diseases• 2. The inflammatory diseases of CNS,

encephalitis, meningitis, polyomielitis, dyphteria

• 3. Postcommotional and postcontusional syndrome

• 4. Polyneuritis (beri-beri, porphyria, thalium’s poisoning)

Classification of the secondary (symptomatical) hypertension

• Exogenic:

• 1. Medicines (corticosteroids, contraceptives, use of radix Glycerrhise)

• 2. Alimentary (thyramin etc.)

The risk-factors that influence the prognosis of hypertension

1. The risk-factors of cardio-vascular diseases that are used for stratification of risk: levels of systolic and diastolic blood pressure, the men (M) over 55, the women (W) over 65 years old, smoking, dyslipidemia (general cholesterol >6,5 mmol/l), the early appearance of cardio-vascular diseases in family (M <40, W<55); abdominal obesity(waist for M ≥102cm, W≥88cm), C-reactive protein ≥1 mg/dl

2. The damage of the target-organs:

hypertrophy of the left ventricle (ECG, EchoECG; EchoECG confirmed thickeness of the arterial wall ( for carotid artery – the thickeness of intima-media ≥0,9 mm) or the presence of atherosclerotic plague; non-considerable increase of creatinin’s level (M 115-133, W 107-124 mcmol/l), microalbuminuria (30-300mg/day)

3. Diabetus

• Glucose in fasting plasma - 7,0 mmol/l

• Glucose in plasma after meal - >11,0 mmol/l

4. Clinical situations that are connected with arterial hypertension:

• Cerebro-vascular diseases: ischemic stroke, cerebral hemorrhage, transit ischemic attack

• Diseases of the heart: myocardial infarction, stenocardia, coronary revascularisation, congenital cardiac failure

• Renal diseases: diabetic nephropathy, broken renal functions (creatinin in serum M>133, W>124 mcmol/l), proteinuria (>300 mg/day)

4. Clinical situations that are connected with arterial hypertension:

• Progressive retinopathy: hemorrhage or exudate, edema and inflammation of the disk of nervus opticus

Stratification of risk to estimate prognosis

• Another risk-factors and diseases in anamnesis

• Another risk-factors are absent

• 1-2 risk factors

• 3 and more risk factors or damage of target organs

• Clinical situation connected with hypertension

• BP systolic 120-129• BP diastolic 80-84

• No risk

• Low risk

• Moderate risk

• High risk

Stratification of risk to estimate prognosis

• Another risk-factors and diseases in anamnesis

• Another risk-factors are absent

• 1-2 risk factors

• 3 and more risk factors or damage of target organs

• Clinical situation connected with hypertension

• BP systolic 130-139• BP diastolic 85-89 • No risk

• Low risk

• High risk

• A very high risk

Stratification of risk to estimate prognosis

• Another risk-factors and diseases in anamnesis

• Another risk-factors are absent

• 1-2 risk factors

• 3 and more risk factors or damage of target organs

• Clinical situation connected with hypertension

• BP systolic 140-159• BP diastolic 90-99, I stage

AH • Low risk

• Moderate risk

• High risk

• A very high risk

Stratification of risk to estimate prognosis

• Another risk-factors and diseases in anamnesis

• Another risk-factors are absent

• 1-2 risk factors

• 3 and more risk factors or damage of target organs

• Clinical situation connected with hypertension

• BP systolic 160-179• BP diastolic 100-109, II

stage AH • Moderate risk

• Moderate risk

• High risk

• A very high risk

Stratification of risk to estimate prognosis

• Another risk-factors and diseases in anamnesis

• Another risk-factors are absent

• 1-2 risk factors

• 3 and more risk factors or damage of target organs

• Clinical situation connected with hypertension

• BP systolic ≥180• BP diastolic ≥110, III stage

AH • High risk

• A very high risk

• A very high risk

• A very high risk

Tactic of treatment

• The patients with a low risk – must be examined for 6-12 months to estimate if they need the medical treatment

• The patients with a moderate risk – for several weeks – until 6 months to decide if they need the medical treatment

• The patients with a high and a very high risk – must get treatment immediately