Hypertension, a disease that kills
Hypertension is a disease of various causes. And as evidenced by the sustained increase in blood pressure or in systole and diastole in both.
The increase in blood pressure (hypertension) is an important cause, but more suitable for treatment disease, and is divided into primary and secondary schools. In the general population, blood pressure is a continuous variable and its increase is associated with an increased risk of disease. Hypertension can be arbitrarily defined as a sustained diastolic pressure greater than 90 mmHg. However, there is no risk of a disease in which pressure Blood is a pathogenic factor.
Primary hypertension (essential) is the elevation of blood pressure with age, but without apparent cause. Represents over 90% of cases and usually appears after age 40, the phenotype of hypertension in hypertension is due to an interaction between genetic predisposition genetics, obesity, alcohol consumption, physical activity and other factors not yet identified.
Secondary hypertension, accounting for about 10% of cases, is due to an identifiable cause, the most common renal vascular disease, which raises blood pressure by activating the renin-angiotensin-aldosterone system. Depending on their clinical outcome, both primary and secondary hypertension can be classified into two types. In benign hypertension, is elevated pressure arterial stable for many years, whereas hypertension accelerates the elevation of blood pressure is intense and worsens in a short period of time.
The factors that regulate blood pressure
Blood pressure can be raised by increasing the volume of the heart or peripheral vascular resistance. The first came up with a blood volume or increased contractility and heart rate, the latter may be enhanced by humoral factors, neural and me.
According to the degree of damage produced organic hypertension, can be found at different stages:
PHASE I: No no functional changes.
PHASE II: The patient has one of the following signs, even when they are asymptomatic.
a) hypertrophy Left ventricular (palpation, chest radiograph, ECG, echocardiogram).
b) Angiotonía in the arteries of the retina.
c) Proteinuria and / or light creatinine elevation (up to 2 mg / d).
d) the arterial plaque (x-ray, ultrasound) in the carotid arteries, aorta, iliac and femoral arteries.
PHASE III: symptomatic manifestations of organ damage:
a) Angina pectoris, myocardial infarction or heart failure.
b) transient cerebral ischemia, cerebral thrombosis and hypertensive encephalopathy.
c exudates) and retinal hemorrhages, papilledema.
d) Inadequate Chronic kidney.
e) aortic aneurysm or atherosclerosis obliterans of lower limbs.
The arterial wall thickening and atherosclerosis are signs of mild hypertension
Hypertension in benign vascular changes occur gradually in response to stable and sustained hypertension. These degenerative changes in the walls of small vessels and arterioles effectively reduces light. consequent tissue ischemia, and increased vascular fragility in the brain at risk bleeding.
In malignant hypertension is a destruction of the walls of small vessels
When blood pressure greatly increases the changes sudden acute destructive occurring in the walls of small blood vessels, along with corrective proliferative responses
walls of small arteries. These alterations caused by lack of blood flow to small vessels, with formation of multiple foci of necrosis, eg in renal glomeruli.
High blood pressure affects mainly the heart, brain, kidneys and aorta
The pathological consequences of hypertension are observed mainly in four tissues:
• Heart. With increasing pressure, ventricular myocardial hypertrophy. Since hypertension is often associated with higher intensity of atherosclerosis, coronary blood flow may be insufficient, and produced a
ischemic heart disease. Left ventricular failure is a consequence normal hypertensive heart disease.
• Brain. Hypertensive patients are particularly prone to intracerebral hemorrhage from ruptured intracranial blood vessels. Damage to the small vessels of the brain hemispheres microinfarctions occurs as small areas of destruction in the brain filled with fluid ("gaps hypertensive).
• Kidney. The progressive arteriolosclerosis ischemia of the nephron, which ends up destroying the glomeruli, and atrophy of the tubular system. The disease progresses slowly, as the injured nephron at a time. When the number of functional nephron by ischemia is not high enough, the patient developed renal chronic renal slowly
progressive. If hypertension occurs significant ischemia of the nephron, the kidney is said to have suffered a mild hypertensive nephrosclerosis. This is an important cause of renal failure
Chronic middle and old age.
• aorta. Hypertension predisposes to the development of large abdominal aortic aneurysms and dissection of the media.
Secondary hypertension is less than 10% of cases
In a minority of cases it is considered that there is some alteration structure responsible for the development of hypertension. For example, stenosis
of the renal artery (usually the root) can cause atherosclerosis by hypertension, surgical treatment possible. Hypertension is associated with elevated levels of renin and angiotensin II in the circulation of kidney ischemic, and can be cured in the early stages through
the elimination of kidney disease. Hypertension is also a symptom of kidney disease diffuse as glomerulonephritis and pyelonephritis. Hypertension is transient in the initial acute phase of glomerular diseases (P, eg.,
Nephritic syndrome acute), but standing diffuse chronic kidney disease.
Pheochromocytoma, an adrenaline-secreting tumor that usually arises noradrenaline in the adrenal medulla, produces hypertension
paroxysmal initially.
Aortic coarctation is a congenital malformation increased peripheral resistance due to stenosis of the structure of the aorta. In these cases, systemic hypertension is not really, since it only affects the blood system before coarctation usually on the arms, head and neck.
Hypertension is a symptom of adrenal cortex diseases associated with overproduction glucocorticoids and mineralocorticoids (Cushing's syndrome and Conn síndromede).
It is also a symptom of preeclampsia, and may be associated with endocrinopathies as thyrotoxicosis, acromegaly, hypothyroidism and some times, or due to neurogenic causes such as intracranial hypertension.
treatment
a) In patients with hypertension grade I or II, we recommend starting treatment with a single drug. If the patient has hypertension hyperkinetic syndrome, the best option is a beta-blocker, is inconvenient and the use of vasodilators such as alpha blockers or calcium antagonists exacerbate circulatory hyperkinesis. In patients suspected to increase the extracellular space (especially women) the best option is the diuretic as monotherapy, are less effective than beta blockers and vasodilators are contraindicated deterioration of fluid retention and expansion of the intravascular space. Can be equally effective ACE inhibitors. In the elderly with hypertension Systolic is preferable to use calcium antagonists as drugs of choice.
b) Patients with grade III essential hypertension requires the use of multiple drugs to achieve effective control of hypertension. This is preferable to start treatment with beta blockers and diuretics (thiazide and potassium-sparing). Failure to reach an effective control of blood pressure can add an ACE inhibitor. When not achieved the normalization of blood pressure can be used vasodilators (Hydralazine, minoxidil, prazosin), which reduce vascular resistance. Calcium antagonists can be used in these patients are not able to control hypertension with drugs and / or because there are two states to end his administration by undesirable side effects, such as gout (thiazides), asthma or heart failure (beta) or persistent cough (ACE inhibitors). Anta calcium antagonists may also produce undesirable side effects (edema, flushing) that may require the suspension or switching to another drug from a different family.
As a general conclusion we can say that the treatment of hypertensive patients should be individualized, taking into account age, clinical conditions and hemodynamic effects of drugs.
c) The patient with grade IV hypertension is a hypertensive emergency or urgency, so its Treatment requires immediate hospitalization and treatment.
Hypertensive Crisis
a) The patient was asymptomatic but with pressure values diastolic blood pressure of 140 mmHg or greater should be hospitalized for observation and bed rest, under the administration of sublingual nifedipine 10 mg.
b) Patient with hypertensive crisis, with blood pressure of 180/140 and acute pulmonary edema should be treated with Fowler's position, sitting on the edge of the bed, rotating tourniquets, IV furosemide at a rate between 20 and 60 mg of sodium nitroprusside and IV diluted in dextrose solution at a rate of 0.3 to 8 mg / kg / min, and in some cases, these measures jugular table does, but others also must examine the patient at the right time (or ouabain lanata C). When the patient is already in clinical conditions will be acceptable to start oral antihypertensive.
c) The patient with hypertensive crisis associated with hypertensive encephalopathy is presented to the doctor with a headache very showy demonstration, nausea, projectile vomiting, blurred vision and a progressive state of clouding of consciousness, all this coincides with elevations exaggerated pressure values pressure (> 180/140). The proper procedure will also be treated with sodium nitroprusside given as mentioned in the previous paragraph, although these cases also diazoxide can be used with an initial dose of 300 mg IV can be repeated w / 4 or 6 hours, depending on the response. Remember that prolonged administration of this drug produces sodium and water retention, so when their use is extended for more than 24 hours should join the administration of diuretics. As soon as possible to start oral treatment.
d) The hypertensive crisis is complicated with aortic dissection is presented as an acute where the patient may have pain chest or back pain accompanied by feelings of death, paleness, sweating and elevated mind exaggerated figures (> 180 / 140 mmHg). This table should be treated with nitroprusside sodium is the drug of choice alfametildopa at a speed of 250 to 500 mg IV c / 4 to 6 hours and checked in to start oral antihypertensive therapy.
e) If a hypertensive crisis due to a pheochromocytoma patient referred headache, palpitations and was found with pallor and diaphoresis, sinus tachycardia and excessively high numbers (> 180/140 mmHg), in which case treatment should be ideal to do with phentolamine, inject an initial bolus of 5 to 15 mg IV and then a continuous drip to maintain blood pressure numbers to acceptable levels. If exageradeamente heart rate is high (> 150 per minute) or atrial tachyarrhythmia appear paroxysmal propranolol should be administered intravenously at a rate of 1 mg / min up to 3 to 5 mg total dose.
Patients with essential hypertension Grade III, require multiple drugs to achieve the desired control. In summary, treatment should be individualized according to age, clinical conditions and hemodynamic sensitivity to drugs.
Prevention methods
* Quitting smoking reduces mortality to half of those continuing smoking.
* The control of hypertension.
* Reduction of body weight.
* Increase physical activity.
* Control of Diabetes
* Changes in eating habits.
The onset may be abrupt, such as myocardial infarction, or may be a chronic disorder, with increasing loss heart function. In turn, this can be compensated for a disease where the activity remains normal or unbalanced, in which the patient suffers from dyspnea and chest pain in this case should rest and receive medication and diuretics.
From a nutritional point of view is the application of a low sodium diet (containing less than 5grs. Daily salt).
In coronary disease should avoid foods rich and abundant as they impose an excessive burden on the heart and circulation.
When choosing food for these patients should be to replace the salt and no abdominal distension, constipation and flatulence.
Bibliography:
• 2007 Pathology Roobins
• Rubin Pathology
• Web of hypertensive crisis Cardiology Journal
• Institute of Cardiology http://www.drscope.com/cardiologia/pac/arterial.htm
• Goodman and Gilman, Farmacologia.
• National Institute of Cardiology - Ignacio Chávez, hypertension items
• Association Mexico's National Cardiologists
• Society of Interventional Cardiology of Mexico
• National Society of echocardiography in Mexico
Nutrition zonadiet.com 2004 • Hypertension
• vascular health. is
• Guyton Physiology Book
• Stevens Pathology
About the Author
Student: School of Medicine Ignacio Santos. Committee member of medical research. Member of the EMC Updates medicas JOURNAL CLUB. Member and Supervisor of medical items since 2007. Member of The Neurology Service On-Line Journal Club. Contributor Renal Pathology MCQs
