Symptomatic arterial hypertension – the secondary gipertenzivny state developing owing to pathology of the bodies which are carrying out regulation of arterial pressure. Symptomatic arterial hypertension the persistent current and resistance to hypotensive therapy distinguishes, development of the expressed changes in target organs (a heart and renal failure, hypertensive encephalopathy, etc.). Definition of the reasons of arterial hypertension demands performing ultrasonography, an angiography, KT, MPT (kidneys, adrenal glands, heart, a brain), researches of biochemical indicators and hormones of blood, monitoring HELL. Treatment consists in medicamentous or surgical impact on the prime cause.
Unlike independent essentsialny (primary) hypertension secondary arterial hypertension serves as symptoms of the diseases which caused them. The syndrome of arterial hypertension accompanies a current over 50 diseases. Among total number of gipertenzivny states the share of symptomatic arterial hypertension makes about 10%. The signs allowing to differentiate them from an essentsialny hypertension (hypertension) are peculiar to the course of symptomatic arterial hypertension:
- Age of patients up to 20 years and over 60 years;
- Sudden development of arterial hypertension with with firmness high level HELL;
- The malignant, quickly progressing current;
- Development of simpatoadrenalovy crises;
- Existence in the anamnesis of etiologichesky diseases;
- Weak response to standard therapy;
- The increased diastolic pressure at renal arterial hypertension.
Classification of symptomatic arterial hypertension
Symptomatic arterial hypertension is divided by primary etiologichesky link on:
1. Neurogenetic (TsNS caused by diseases and defeats):
- central (injuries, brain tumors, meningitis, encephalitis, stroke, etc.)
- peripheral (polyneuropathies)
2. Nefrogenny (kidney):
- interstitsialny and parenchymatous (pyelonephritis chronic, glomerulonefrit, , nephrosclerosis, , system red a wolf cub, )
- renovaskulyarny (atherosclerosis, a dysplasia of vessels of kidneys, vaskulita, thromboses, aneurisms of a renal artery, tumors squeezing kidney vessels)
- mixed (, congenital anomalies of kidneys and vessels)
- renoprinny (a state after removal of a kidney)
- nadpochechnikovy (feokhromotsitoma, Conn's syndrome, giperplaziya of bark of adrenal glands)
- tireoidny (hypothyroidism, thyrotoxicosis) and paratireoidny
- hypophysial (akromegaliya, Itsenko-Cushing's disease)
4. Haemo dynamic (caused by defeat of the main vessels and hearts):
- stenosis vertebrobazilyarny and carotids
- aorta kaorktation
- insufficiency of aortal valves
5. Dosage forms at reception mineralo-and glucocorticoids, progesterone - and estrogensoderzhashchy contraceptives, a levotiroksin, salts of heavy metals, indometacin, licorice powder, etc.
Depending on the size and firmness HELL, expressivenesses of a hypertrophy of the left ventricle, the nature of changes of an eye bottom distinguish 4 forms of symptomatic arterial hypertension: tranzitorny, labile, stable and malignant.
Tranzitorny arterial hypertension is characterized by unstable increase HELL, changes of vessels of an eye bottom are absent, the left ventricular hypertrophy is practically not defined. At labile arterial hypertension the moderate and unstable increase HELL which is not decreasing independently is noted. Poorly expressed hypertrophy of the left ventricle and narrowing of vessels of a retina is noted.
HELL, hypertrophy of a myocardium and the expressed vascular changes of an eye bottom (angioretinopatiya of the I-II degree) are characteristic of stable arterial hypertension resistant and high. Malignant arterial hypertension is distinguished sharply raised and stable BY HELL (in particular diastolic> 120 — 130 mm of mercury.), the sudden beginning, bystry development, danger of heavy vascular complications from heart, a brain, the eye bottom defining the adverse forecast.
Forms of symptomatic arterial hypertension
Nefrogenny parenchymatous arterial hypertension
The most often symptomatic arterial hypertension has a nefrogenny (kidney) origin and is observed at sharp and chronic glomerulonefrita, chronic pyelonephritises, a polikistoza and a hypoplasia of kidneys, gouty and diabetic nefropatiya, injuries and tuberculosis of kidneys, an amiloidoza, hard currency, tumors, a nefrolitiaza.
Initial stages of these diseases usually proceed without arterial hypertension. Hypertensia develops at the expressed defeats of fabric or the device of kidneys. As features of renal arterial hypertension serve mainly young age of patients, lack of cerebral and coronary complications, development of a chronic renal failure, malignant character of a current (at chronic pyelonephritis – in 12,2%, a chronic glomerulonefrit – in 11,5% of cases).
In diagnosis of parenchymatous renal hypertensia use ultrasonography of kidneys, an urine research (the proteinuria, a gematuriya, a tsilindruriya, a piuriya, a gipostenuriya – the low specific weight of urine come to light), definition of creatinine and urea in blood (the azotemiya comes to light). For a research of sekretorno-excretory function of kidneys carry out an isotope renografiya, urography; in addition - an angiography, UZDG of vessels of kidneys, MPT and KT of kidneys, a biopsy of kidneys.
Nefrogenny renovaskulyarny (vazorenalny) arterial hypertension
Renovaskulyarny or vazorenalny arterial hypertension develops as a result one - or bilateral violations of an arterial kidney blood-groove. At 2/3 patients as the reason of renovaskulyarny arterial hypertension serves atherosclerotic damage of renal arteries. Hypertensia develops when narrowing a gleam of a renal artery for 70% and more. Systolic HELL is always higher than 160 mm ., diastolic – more than 100 mm hg.
The sudden beginning or sharp deterioration in a current, tolerance to medicinal therapy, a high share of a malignant current is characteristic of renovaskulyarny arterial hypertension (at 25% of patients).
Are diagnostic signs of vazorenalny arterial hypertension: systolic noise over a projection of a renal artery, defined at an ultrasonografiya and urography – reduction of one kidney, contrast removal delay. On ultrasonography – the ekhoskopichesky signs of asymmetry of a form and the sizes of kidneys exceeding 1,5 cm. The angiography reveals concentric narrowing of the affected renal artery. Duplex OUSE scanning of renal arteries defines violation of the main kidney blood-groove.
In lack of treatment of vazorenalny arterial hypertension 5-year survival of patients makes about 30%. The most frequent causes of death of patients: brain strokes, myocardial infarction, sharp renal failure. In treatment of vazorenalny arterial hypertension apply both medicamentous therapy, and surgical techniques: angioplasty, stenting, traditional operations.
At a considerable stenosis prolonged use of medicamentous therapy is unjustified. Medicamentous therapy gives short and changeable effect. The main treatment – surgical or endovascular. At vazorenalny arterial hypertension installation of the intra vascular stent expanding a gleam of a renal artery and preventing its narrowing is carried out; balloon dilatation of the narrowed site of a vessel; reconstructive interventions on a renal artery: a resection with imposing of an anastomoz, prosthetics, imposing of roundabout vascular anastomoz.
Feokhromotsitoma – the gormonoprodutsiruyushchy tumor developing from chromaffine cells of brain substance of adrenal glands makes from 0,2% to 0,4% of all found forms of symptomatic arterial hypertension. Feokhromotsitoma sekretirut catecholamines: noradrenaline, adrenaline, dopamine. Their current is followed by arterial hypertension, with periodically developing hypertensive crises. Besides hypertensia at feokhromotsitoma severe headaches, the increased sweating and heartbeat are observed.
Feokhromotsitoma is diagnosed at detection of the increased maintenance of catecholamines in urine, by carrying out diagnostic pharmacological tests (test with a histamine, tiraminy, a glucagon, clonidine, etc.). Allows to specify localization of a tumor ultrasonography, MPT or KT of adrenal glands. It is possible to determine by carrying out radio isotope scanning of adrenal glands hormonal activity of a feokhromotsitoma, to reveal tumors of vnenadpochechnikovy localization, metastasises.
Feokhromotsitoma are treated exclusively surgically; before operation correction of arterial hypertension α-or β – adrenoblokator is carried out.
Arterial hypertension at Conn's syndrome or primary giperaldosteronizm is caused by aldosteronprodutsiruyushchy adenoma of bark of adrenal glands. Aldosteron promotes redistribution of ions To and Na in cages, to deduction of liquid in an organism and to development of a gipokaliyemiya and arterial hypertension.
Hypertensia practically does not give in to medicamentous correction, attacks of a myasthenia, a spasm, a paresteziya, thirst, a niktruriya are noted. Hypertensive crises with development of sharp left ventricular insufficiency (cardiac asthma, hypostasis of lungs), a stroke, gipokaliyemichesky paralysis of heart are possible.
Diagnostics of primary aldosteronizm is based on definition in plasma of level of an aldosteron, electrolytes (potassium, chlorine, sodium). High concentration of an aldosteron in blood and its high ekskretion with urine, metabolic ( blood - 7,46-7,60), a gipokaliyemiya is noted (a radio isotope research and ultrasonic scanning of adrenal glands reveals increase in the adrenal gland affected aldosteromy or a bilateral giperplaziya of bark of adrenal glands.
At the malignant arterial hypertension caused by aldosteromy the surgical treatment allowing to normalize is carried out or to considerably lower HELL at 50-70% of patients. Before carrying out surgical intervention the hyposodium diet, treatment by the antagonist of an aldosteron – spironolaktony, stopping a gipokaliyemiya and arterial hypertension is appointed (on 25 — 100 mg in each 8 h).
Syndrome and Itsenko-Cushing's disease
Endocrine arterial hypertension develops at 80% of patients with a disease and Itsenko-Cushing's syndrome. Hypertensia is caused by hyper secretion of glucocorticoid hormones bark of adrenal glands (giperkortitsizm) and HELL differs in a stable, beskrizovy current, resistance to hypotensive therapy, proportional increase systolic and diastolic. Other characteristic display of diseases is kushingoidny obesity.
At Itsenko-Cushing's syndrome/disease in blood the level 11 and 17-OKS, a kortikotropina, a hydrocortisone increases. In urine the ekskretion 17-KC and 17-OKC is raised. For differential diagnostics between kortikosteromy and adenoma of a hypophysis are carried out by MPT and KT of adrenal glands, a hypophysis, ultrasonic and radio isotope scanning of adrenal glands, a kraniogramma. Treatment of a giperkortizizm and the arterial hypertension caused by it can be medicamentous, surgical or beam.
Koarktation of an aorta
Koarktation of an aorta – the congenital malformation of an aorta which is shown its segmentary narrowing interfering a blood-groove of a big circle. Koarktation of an aorta is seldom found form of arterial hypertension.
At the secondary arterial hypertension caused by an aorta koarktation the difference to HELL, measured on hands (raised) and legs (normal or lowered), increase HELL at the age of 1-5 years and its stabilization after 15 years, easing or lack of a pulsation on femoral arteries, strengthening of a warm push, systolic noise over a top, the heart basis, on carotids is observed. Diagnosis at a koarktation of an aorta is based on a X-ray analysis of lungs and bodies of a thorax, an aortografiya, an echocardiography. At the expressed degree of a stenosis surgical treatment is carried out.
Dosage forms of arterial hypertension
Development of dosage forms of arterial hypertension the vascular spasm, increase in viscosity of blood, a delay of sodium and water, influence of medicines on a renin-angiotenzinovuyu can cause system etc. Intranazalny drops and the cold medicines containing adrenomimetik and simpatomimetik in the structure (pseudoephedrine, ephedrine, ), can cause arterial hypertension.
Reception of nonsteroid anti-inflammatory medicines causes development of arterial hypertension owing to a delay of liquid and suppression of synthesis of prostaglandins having vazodilatiruyushchy effect. The oral contraceptives containing estrogen have the stimulating effect on a renin-angiotenzinovuyu system and cause a liquid delay. Secondary arterial hypertension develops at 5% of the women using oral contraception.
The stimulating action on sympathetic nervous system of tritsiklichesky antidepressants can cause development of arterial hypertension. Application of glucocorticoids raises HELL in view of increase in reactivity of vessels in relation to angiotensin II.
Detailed collecting the medicinal anamnesis of the patient, the analysis of a koagulogramma, definition of a renin of blood is necessary for establishment of the reason and a form of secondary arterial hypertension for the cardiologist.
Neurogenetic arterial hypertension
Arterial hypertension of neurogenetic type is caused by damages of a head or spinal cord at encephalitis, tumors, ischemia, to a craniocereberal trauma, etc. Krom of increase HELL the expressed headaches and dizzinesses, tachycardia, perspiration, a salivation, vasomotorial skin reactions, belly-aches, , convulsive attacks are typical for them.