Essential hypertension-What is essential hypertension?
Essential hypertension - Disease Overview
Blood pressure measurement Hypertension (hypertension) is the adult (≥ 18 years), systolic blood pressure ≥ 140mmHg in a quiet state (18.7kPa) and (or) diastolic blood pressure ≥ 90mmHg (12.0kPa), often accompanied by fat and glucose metabolism disorders, as well as the organ of the heart, brain, kidney and retina functional or organic changes, that is, the organ remodeling (remodeling) is characterized by systemic disease. Variety of risk factors and pathogenesis of the disease may have caused dysfunction of the central nervous system, humoral, endocrine, genetic, kidneys, blood vessels, baroreceptor dysfunction, cell membrane ion transport abnormalities, as well as environmental factors, living habits, social factors and so may be involved in the pathogenesis process. For reasons not fully elucidated high blood pressure, called essential hypertension. Clear, the cause of high blood pressure just a manifestation of certain diseases, known as the secondary (symptomatic) hypertension.
Hypertension classification and typing:
An etiology can be divided into primary and secondary (symptomatic) two categories.
Blood pressure levels classified according to the 1999 WHO-ISH hypertension treatment guidelines, hypertension is the case of not taking antihypertensive medication, 18-year-old adult systolic blood pressure ≥ 140mmHg (18.7kPa) and (or) diastolic blood pressure ≥ 90mmHg (12.0kPa).
Adult self-test blood pressure 135/85mmHg (18.0/11.3kPa) normal, 24h blood pressure monitoring during the day and sleep at night <135/85mmHg (18.0/11.3kPa), <120/75mmHg (16.0/10.0kPa) normal, more than The above data is high blood pressure.
Essential hypertension - symptoms and signsHypertension right ventricular enlargement, symptoms of hypertension according to clinical characteristics and progression of speed, can be divided into a jog (slow type) hypertension and radical (malignant) hypertension. (% Of essential hypertension in 95% ~ 99%) belong to jog hypertension essential hypertension, more common in the elderly, which is characterized by insidious onset, slow progress in the course of more than 10 years to decades , so very few symptoms early, about half of the patients due to a medical examination or measurement of blood pressure when the medical treatment of other diseases, only occasional blood pressure.Target organ damage symptoms
(1) heart: heart damage symptoms of hypertension and blood pressure continues to rise about, which can increase the left ventricular afterload, leading to cardiac hypertrophy, followed caused the chambers of the heart to expand and repeated heart failure attack.
(2) kidney: primary hypertensive renal damage and to the renal arteriolosclerosis, in addition, adjustment disorder is also related to the kidney itself. Early urinary symptoms, nocturia increased with urinary electrolyte excretion increased with disease progression, indicating that the renal concentration function has begun to decline, followed by the urine abnormalities, such as proteinuria, tubular, red blood cells, renal function diminished urine relative density (specific gravity) is often fixed at about 1.010, β2-microglobulin in urine increased due to renal tubular damage to make. Hypertension and severe kidney damage can occur when the symptoms of chronic renal failure.
(3) of the brain: high blood pressure can lead to cerebral small artery spasm, resulting in headache, dizziness, stretching, vertigo and other symptoms when blood pressure suddenly increased significantly hypertensive encephalopathy, severe headache, vomiting, vision loss, convulsions , coma, cerebral edema and intracranial hypertension symptoms, if not timely rescue can be fatal. Brain the most important complications of hypertension cerebral hemorrhage and cerebral infarction.
Essential hypertension - disease etiologyHypertension treatment instrument high blood pressure related to many factors, including the following factors:(1) gender and age the world's most areas, the prevalence of hypertension in men than in women.
(2) career in the mental and the intense work of hypertension prevalence than manual workers, urban residents than rural residents a high prevalence and early age of onset.
(3) the diet and blood pressure has been confirmed that excessive sodium intake, heavy drinking, long-term drinking strong coffee, lack of calcium in the diet, saturated fatty acids in the diet too much, unsaturated fatty acids and saturated fatty acid ratio lower, can promote increased blood pressure .
4 smoking
Obesity and ultra volume
6 genetic
Seven different regions of the regional differences in population blood pressure levels are not the same northern areas, the average population systolic blood pressure higher than the southern region, the prevalence of hypertension also increased accordingly.
8 psychological factors.
Essential hypertension - pathophysiologyBlood pressure measurement to count the pathogenesis of essential hypertension, the following factors play an important role in the pathogenesis of hypertension.(1) the pathogenesis of
(1) cardiac output changes: early hypertensive patients often have increased cardiac output, showed that the increase in cardiac output play a role in the initiating mechanism of essential hypertension may be associated with sympathetic activation and catecholamine secretion of active substances related to the increase .
(2) the kidneys factors: renal regulation of water, electrolytes, blood volume and excretion of metabolites of the main organs, abnormal renal function can lead to water and sodium retention and increased blood volume, causing high blood pressure.
(3) The renin - angiotensin - aldosterone system (RAAS): The system consists of a series of hormones and enzymes composed of RAAS plays an important role in regulating water and electrolyte balance and blood volume, vascular tone and blood pressure.
(4) membrane ion transport abnormalities: through the cell membrane on both sides of sodium and potassium ion concentration and gradient has been confirmed in patients with essential hypertension exist within the sodium, potassium co-operation dysfunction and sodium pump inhibition, intracellular sodium ion increased.
(5) increase in sympathetic activity: the sympathetic nerves are widely distributed in the cardiovascular system. The role of increased sympathetic activity in the heart, can lead to faster heart rate, myocardial contractility and to strengthen and increase in cardiac output; role in vascular α receptor allows small artery contraction, the increase in peripheral vascular resistance and blood pressure.
(6) increased vascular tone, wall thickening: blood circulation to regulate their own imbalances, leading to increased tension of small arteries and small veins, hypertension.
(7) vasodilators: the body in addition to the liters of blood pressure, material and systems, there are many endogenous decompression (vasodilator) substances and systems to be antagonistic to maintain relatively stable blood pressure. Have a strong vasodilator prostaglandin (PG) substances (such as of PGl2, PGF2, and PGA2, etc.) to reduce, increase peripheral vascular resistance, so that the blood pressure.
2 of Pathology
Artery (1): mainly for high blood pressure early arterial contraction and tension increased over time, high blood pressure by affecting the vascular endothelium and smooth muscle cells, leaving the artery wall intimal permeability changes, manifested as intimal surface is not smooth, not smooth, followed by the increased permeability of the arterial wall, circulating red blood cells, platelets into the intima and adhesion in the area and intimal deposition and proliferation of smooth muscle cells from the middle tour to the thickening of the intima, connective tissue increased, so the wall thickening and hardening, luminal narrowing, or occlusion, can lead to arteriosclerosis.
(2) of the heart: heart hypertension one of the target organ, the disease can lead to cardiac function and changes in the structure, long-term blood pressure and heart continues to remain overloaded state, can cause left ventricular hypertrophy, mainly for the left Room concentric hypertrophy, ie, wall, interventricular septum was symmetrical hypertrophy, ventricular cavity does not expand, more common in peripheral resistance was significantly increased cardiac output is relatively low nor heart failure in patients with hypertension; cardiac output is relatively high or repeated heart failure patients, can be expressed as eccentric hypertrophy, the ventricular cavity to expand, but the wall and the room cavity ratio does not increase.
(3) kidney: primary benign hypertension on kidney damage manifested as benign renal arteriosclerosis, due to the slow progress of the disease, elderly patients with a higher prevalence, it is the pathological basis of hypertensive kidney disease to afferent arterioles and interlobular arteriosclerosis mainly followed can cause renal ischemia, atrophy, fibrosis and necrosis, leading to chronic renal insufficiency, kidney disease can aggravate high blood pressure, creating a vicious cycle.
(4) brain: the brain is high blood pressure the most important target organ, is also suffering from hypertension the main reason of death or disability.
(5) Other: high blood pressure the body can affect all organs, ocular lesions are also common hypertensive complications, retinal arteriosclerosis and retinopathy is the most important, can be expressed as retinal vascular spasm, contraction, exudation, hemorrhage, and optic disc edema can lead to patients with visual acuity and ocular symptoms appears.
Essential hypertension - diagnostic testsBlood pressure measurement except first diagnosis of primary hypertension secondary hypertension.Stage, grade, and risk stratification of hypertension:
(1) the classification of hypertension: the medication, systolic blood pressure (SBP) ≥ 18.7kPa (140mmHg) and (or) diastolic blood pressure (DBP) ≥ 12.0kPa (90mmHg). Grading standards of the 1999 WHO recommended blood pressure levels of adults over the age of 18.
(2) hypertension in the standard of risk stratification.
Laboratory tests:
Urine and renal function test may be negative or have a small amount of protein and red blood cells. Often rapidly progressive hypertension in patients with urinary protein, red blood cells and tubular renal dysfunction often have a lot of protein, red blood cells and casts.
(2) renal dysfunction, urine specific gravity low and fixed, to reduce the excretion of phenol red, serum creatinine and urea nitrogen levels, urea or endogenous creatinine clearance rate of less than normal.
(3) plasma renin activity and angiotensin II concentration, both may be normal, increase or decrease. Also measured plasma atrial natriuretic peptide concentration, and often reduced.
Other laboratory examinations:
1.X-ray examination of left ventricular hypertrophy to expand, aortic widening, extension and twist the heart shadow was the change in aortic type. Visible pulmonary congestion signs of left ventricular dysfunction.
2 ECG left ventricular hypertrophy, strain. In addition, there may be a variety of arrhythmias, left bundle branch block graphics. And coronary heart disease, angina or myocardial infarction may be the corresponding ECG changes.
Echocardiography, two-dimensional ultrasound early left ventricular wall pulsatility enhanced hypertension heart disease, more common septal hypertrophy, left ventricular posterior wall hypertrophy and left atrium were enlarged, ultrasound Doppler mitral enable the detection of early diastolic blood flow slowed down, end-diastolic velocity increased.
Fundus examination showed retinal artery spasm and (or) sclerosis, serious bleeding and oozing, optic disc edema.
Arterial blood pressure monitoring nearly 10 years the rapid development of new diagnostic technologies, contribute to the diagnosis of hypertension and determine the treatment effect.
Differential diagnosis:Must bear in mind the two majority in the diagnosis of hypertension in the differential diagnosis: First, the majority of the hypertensive population with essential hypertension; two patients with secondary hypertension, the majority of the etiology and kidney, including renal parenchyma ( renal hypertension, renin tumors, etc.), renal artery (renovascular hypertension), as well as the adrenal cortex, primary aldosteronism, and adrenal medulla chromaffin cell tumor. Differential diagnosis, it is impossible it is not necessary to the implementation of the measures of each of the differential diagnosis of each type of secondary hypertension in patients with hypertension.
Essential hypertension - treatment optionsHypertension treatment instrument. The basic principles(1) the treatment of hypertension must take comprehensive measures: the varying degrees of hypertension should be treated separately. Moderate and severe hypertension should begin as soon as possible treatment; mild hypertension, diastolic blood pressure continued after the 90 ~ 99mmHg patients with non-drug measures, invalid application of antihypertensive drugs.
(2) non-drug treatment measures: such as weight loss, weight control, low-salt diet, quit alcohol, appropriate sports and doing qigong, tai chi, etc., applicable to various degrees of hypertension. Mild hypertension by about half a year of non-drug therapy should be used antihypertensive drugs. Already and have diabetes, left ventricular hypertrophy, coronary heart disease patients, even if the blood pressure mildly elevated early drug treatment to reduce and reduce cardiac complications.
(3) mild to moderate hypertension: the general use of an antihypertensive drug can be effective, should be based on the patient's general condition, the choice of side effects, easy to take drugs; severe hypertension or severe complications of hypertension should be used in combination, to control blood pressure as soon as possible, generally two to three kinds of antihypertensive drugs can be. Antihypertensive drugs is best to apply the long-acting agents, the antihypertensive effect can be maintained at more than 24h, 24h blood pressure trough to peak ratios should be> 50% in order to avoid wide fluctuations in blood pressure one day.
(4) the principle of individualized: each hypertensive patients is variable, its pathogenesis is not the same on the response to antihypertensive drugs are also different, so must be treated in the clinical treatment process, select the most appropriate drug and dose. to obtain the best effect.
(5) except in cases of hypertensive crisis, hypertensive encephalopathy, hypertensive emergency, blood pressure should be decreased gradually after a few days or 1 to 2 weeks as well, to avoid short-term blood pressure dropped sharply, to avoid the heart, brain, renal agenesis blood symptoms, especially in elderly patients.
(6) of antihypertensive therapy: blood pressure control in patients with severe hypertension, elderly patients with hypertension or with marked cerebral arteriosclerosis, renal insufficiency, by the joint treatment of blood pressure still can not be ≤ 140/90mmHg or 140/90mmHg following the symptoms actually worsened, the blood pressure is controlled at 140 to 150/90 ~ 95mmHg can lower blood pressure, too much may even lead to heart, brain, kidney ischemia, aggravate the disease and complications.
(2) non-drug treatment (1) weight loss, weight control (2) low-salt diet (3) limit alcohol consumption and smoking cessation (4) sports.
Hypertension Yishi fruit. Drug treatment(1) commonly used antihypertensive drugs:
① diuretic antihypertensive drugs: thiazides: hydrochlorothiazide thiophene hydrochloride (hydrochlorothiazide in urine plug, of hydrochlorothiazide, of HCT) 12.5 to 25mg, 1 times / d; benzyl fluoride thiophene hydrochloride (bendrofltlazide) 5mg, 1 to 2 / d; cyclopentyl thiazide 0.25mg 1 / d; hydrogen fluoride thiazine (hydroflumethiazide) 12.5mg, 1 / d; parked and thiazide (thiazide) (polythiazide) 2mg, 1 times / d; A chlorine thiazide 2.5mg, 1 times / d; the B thiazide (ethiazide) 2.5mg, 1 times / d; ring thiazide (cyclothiazide) 0.5 to 1 mg / d. (b) of chlorthalidone and similar to the thiazide diuretics: ① The Chlorthalidone (chlorthalidone) 12.5 to 25mg / d, day or once every other day; 2 chlorine Sauron (chlorine ring indanone) 20 ~ 40mg / d, 1 or 2 times service; ③ The US Fuxi Te (times can be reduced mefruside bycaron) 25 ~ 50mg / d; ④ The indapamide (indapamide) is a diuretic and antihypertensive drugs with calcium antagonism, 1.25 to 2.5 mg, 1 / d; the ⑤ Kuiyi yl ketones (quinethazone,) 25 ~ 50mg / d. (c) the medullary loop of the ascending branch of the diuretic antihypertensive drugs, according to Thani acid (ethacrynic acid), furosemide and mercury Sali (less) the end of the (d) distal convoluted tubule and collecting tube cortex diuretic antihypertensive drugs: spironolactone (security the spironolactone antisterone, contained spironolactone), triamterene (triamterene, three ammonia neopterin), amiloride (amlodipine and topiramate microphone, amiloride).
The ② adrenergic blockers: A.β blockers include: (a) propranolol (of propranolol, propranolol) (b) A atenolol (atendol, tenormin, atenolol) c. America Trotsky Seoul (of metoprolol, betaloc, metoprolol, methoxy B peace of mind) (d) thiophene timolol (timolol, timolol): is a potent non-selective beta receptor blockers, 2 hours after taking up the role of peak 5 10mg / d, 2 ~ 3 times / d. e. nadolol (nadolol, Kang Jiaer more naphthalene hydroxyl peace of mind): is a non-selective beta-blockers For no endogenous sympathomimetic activity, is a long-acting formulations, oral administration of 1 / d dose 40 ~ 200mg. f. Betaxolol (betaxolol): selective β1 receptor blockers, without intrinsic sympathomimetic activity at a dose of 5 ~~ 20mg / d. (g) Bisoprolol (bisoprolol, Concord): is a selective β1 receptor blocker use for the 2.5 ~ 10mg, 1 / d. B. acting on the central α-receptor blocking drugs: clonidine (of clonidine, catapres, clonidine) b. To Guanidine that benzyl (chlorine pressure guanidine) (c) methyldopa (methyldopa, aldomet) d. Guanidine France Xin (guanfacine) e hydrochloride Los non-Western set (lofexidinehydrochloride) C. ganglion blockers: a. U.S. Kala Ming (mecamylamine) b. camphor sulfonamide Mi Fen (Mi-fen, Alfonso Linate) c Pan will pyridine (pempidine, the, Wujia piperidine).
③ vasodilators: can be divided into two categories, one is a direct effect on vascular smooth muscle to cause vasodilation, including nitrates, sodium nitroprusside, hydrazine, hydralazine and other drugs; indirect vasodilators, including calcium antagonists alpha receptor blockers and angiotensin-converting enzyme inhibitors.
④ angiotensin-converting enzyme inhibitors: the commonly used drugs: captopril (captopril, captopril): 15 ~ 30min after oral administration began to buck up to the peak effect in 1 ~ 1.5h lasted 8 ~~ 12h typical doses of 6.25mg, 3 times / d, increasing to 12.5 ~ 25mg, 3 times / d, the maximum dose is 100 to 150mg / d. Adverse reactions are dizziness, abdominal discomfort, headache, fatigue, loss of appetite and coughing, impaired renal function should reduce the dose or extend the delivery time. Should not also apply to the retention of potassium-sparing diuretics or potassium preparations, in order to avoid potassium increased; is a second generation of angiotensin converting enzyme inhibitors, without thiol (SH), the maximum antihypertensive effect of enalapril (for enalapril): medication after 6 ~ 8h appear, lasted for 12 ~ 24h. Began to measure the 5mg, 1 ~ 2 times / d, the usual dose is 10 to 20mg / d, the maximum dose of 40mg / d. Adverse events with captopril, but lighter; lisinopril (lisinopril has been used): a long-acting formulations, mechanism of action similar to enalapril. Usage: a starting dose of 5mg / d, gradually increase the amount, the usual dose of 20 ~ 40mg / d, the maximum dosage should not exceed 80mg / d; ramipril (the ramipril, Ruitai) and: long-acting ACEI agents a starting dose of 2.5mg / d, increasing to 5 ~ 10mg / d; lisinopril (lisinopril has been used): the starting dose of 10mg / d, increasing to 80mg / d; Cilazapril (cilazapril, inhibace, ): start the dosage of 2.5mg / d, depending on blood pressure can be gradually increased to 5 ~ 20mg / d; benazepril (benazepril): The starting dose of 5mg / d, increasing to 10 ~ 40mg / d, sub- 1 to 2 doses; perindopril (perindopril, acertil, Acertil): The starting dose of 4 mg / d, may be increased to 8mg / d; fosinopril (fosinopril, monopril, Monopril): a starting dose of 10mg / d, may be increased to 20 to 30mg / d; the the ⑩ hydrochloride Quinapril (quinaprilhydrochloride, accupril): a starting dose of 5mg / d, may be increased to 20mg / d.
⑤ The of Ang II receptor l subtypes (AT1) antagonists: their chemical structure can be divided into three categories: ① The biphenyl tetrazole, the main drugs: losartan (losartan, cozaar Cozaar), the usual dose 50mg / d, if necessary, may be increased to 100mg / d; commonly used doses of irbesartan (irbesartan) for 75 ~~ 300mg / d; Kant losartan (the candesartan) commonly used dose of 4 to 32mg / d; Suosha Tan ( the tasosartan) the usual dose of 100 ~ 200mg / d; ② The non-biphenyl tetrazole, the main drugs: Ipp losartan (eprsatan,) the usual dose of 400 to 800mg / d; Tian Mei losartan (with telmisartan) 20 to 160mg / d ; ③ non-heterocyclic valsartan (valsartan, diovan, Diovan) commonly used dose is 80 to 160mg / d.
Essential hypertension - Prognosis PreventionThe prognosis of the treatment of high blood pressure medicines: Hypertension is a heterogeneous disease of genetic susceptibility and environmental factors, the strength of individual risk factors and causative agent different, different individual life when the incidence varies from person to person. At the same time, the hypertension early lack of clinical symptoms, it is difficult to determine one patients with hypertension duration of the "starting point". On the other hand, the natural course of disease or prognosis of hypertension by a variety of other risk factors, therefore, accurately describe the course of hypertension more difficult. Hypertensive patients with average life expectancy of 15 to 20 years shorter than normal, but different in different individuals.Prevention: the prevention of hypertension should not only reduce the prevalence of hypertension, is more important is to reduce or delay the emergence of cardiovascular and cerebrovascular complications. Hypertension prevention and divided into three: to take preventive measures in the primary prevention of high-risk groups for hypertension, but also for the general population, in the presence of risk factors but have not yet developed hypertension. Secondary prevention system for the diagnosis of patients with essential hypertension in a planned comprehensive treatment to prevent exacerbations or complications, in essence, arteriosclerosis, stroke, coronary heart disease, such as a prevention. Tertiary prevention refers to the rescue of the weight in patients with hypertension in critical condition, prevent complications and reduce deaths, but also include the rehabilitation after the successful rescue. Clearly, hypertension prevention emphasis in primary prevention and secondary prevention.
Hypertension is a preventive measure
(1) lose weight: overweight and obesity is a major risk factor of hypertension, according to the standard body mass index> 23 referred to as overweight. The weight loss of the main measures is to restrict over-eating, increasing physical activity.
(2) a reasonable diet: to reduce sodium intake, an appropriate increase of potassium, calcium, magnesium intake, reduce fat in the diet.
(3) limit alcohol consumption: that was a U-shaped curve relationship between alcohol consumption and blood pressure, and a threshold response (40g of alcohol threshold), for the prevention of hypertension, the best non-drinkers; drinking habits. alcohol or to minimize alcohol consumption (<50m1 / d).
(4) increased physical activity: the risk of hypertension of less physical activity is physical activity more than 1.52 times, therefore, advocates insist on regular physical activity, especially aerobic exercise.
(5) psychological balance: the psychological pressure caused by personal factors and environmental factors often makes the patients taken to unhealthy lifestyles, the latter related to increased risk of hypertension and cardiovascular disease should therefore be treated correctly and try to alleviate the psychological pressure .
The rational treatment of hypertension secondary prevention measures for hypertension include:
(1) The application is simple, effective, safe, inexpensive antihypertensive drugs to lower blood pressure to normal.
(2) protection of target organs.
(3) taking into account the treatment of other risk factors.
(4) improve the quality of life. In short, comprehensive measures should be taken to vary the individual therapy, to achieve the best results.
3 to carry out the comprehensive prevention and control of high blood pressure community is a fundamental way.
(1) Hospital Health Education: various types and levels of health care institutions and their staff, the purposes of health care in clinical practice, the implementation of health education, tertiary prevention through health education.
(2) Community prevention and control: the establishment of prevention and control network, and personnel training. Epidemiological investigation, including a baseline survey and forward-looking heart, cerebrovascular disease survey. Population grouping and implementation of interventions, to participate in the prevention and control of the object were randomized three preventive measures, the implementation of the intervention group.
4. Cardiovascular multiple risk factors for joint intervention in several population studies show that, although randomized clinical trials have confirmed the benefits of lower blood pressure, but, after treatment in hypertensive patients with coronary heart disease, the incidence of stroke and total mortality rate was still significantly higher than non-hypertensive patients. Observations suggest that the treatment of hypertensive patients with non-hypertensive patients, the former is more severe atherosclerosis, LVN more obvious. Therefore proposed that produce complications of hypertension, multiple risk factors involved in cardiovascular multiple risk factors for joint intervention in the prevention and treatment of hypertension should be conducted.
The intervention of other risk factors: weight loss, exercise, reduce fibrinogen can improve cardiovascular disease risk, but has not yet been confirmed by large clinical trials. Supplementary anti-oxidative vitamins such as vitamin C, vitamin E and cysteine reduce vitamin such as folate, vitamin B12.
