Aug 19, 2020 in Medicine

Hypertension

Introduction

Like many diseases, hypertension does not occur suddenly, even if it seems so. As a rule, before it is detected, changes occur in the body of a patient, which, at the same time, are almost unnoticeable. Furthermore, an increase in blood pressure may have severe consequences and complications, including a brain stroke and myocardial infarction. These complications can make a person disabled for life and even lead to his or her death. Hypertension becomes especially dangerous in case, when the measures aimed at mitigating of its effects are not taken immediately. As a result, the knowledge about features of hypertension and ways to keep the blood pressure on the normal level determines the health of a nation. Therefore, the following research focuses on the pathophysiology and approaches to the treatment of this disorder.

Pathophysiology

Hypertension (high blood pressure) is a rather frequent disorder, for which many people do not pay attention. However, being left uncontrolled, it increases the risk of serious health problems, including heart attacks and strokes. Depending on its origin, it is possible to distinguish an essential and symptomatic hypertension. The first one develops independently, rather than as co-morbidly, accounting for about 95% of all the cases of hypertension. In the second case, the most frequent causes of this disorder include kidney disease (renal arterial hypertension) and narrowing of the renal arteries (renovascular hypertension). A symptomatic hypertension is also observed in a number of endocrine diseases, pathological climax, thyrotoxicosis, disorders of the central neural system, as well as in the case of some congenital and acquired heart defects. The diagnostics of any type of hypertension involves the use of several methods. The first of them is the measurement of the arterial blood pressure, which should not increase 140 and 90 mm Hg for the systolic and diastolic pressure respectively. The next method is a physical examination of the heart using a stethoscope. Its primary goal is the confirmation of the presence of a heart murmur, as well as the appearance of uncharacteristic sounds. Finally, it is possible to make an electrocardiogram to detect various cardiac arrhythmias, as well as the potential hypertrophy of the left ventricular wall, which is typical for hypertension. For the best results, it is advisable to use several methods of diagnostics, prioritizing the electrocardiogram.

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The high blood pressure occurs due to the combined effect of the two hemodynamic parameters – a growing resistance to blood flow in arterioles and arteries of the systemic circulation and a significant increase in the cardiac output. An additional mechanism for the development of hypertension may be an increase in the volume of circulating blood. An increase in cardiac output affects the systolic blood pressure of a patient, while an increase in the peripheral resistance to blood flow has an effect on the diastolic one. During the hypertensive disease, an increase in the peripheral blood flow resistance plays a vital role. In the case of aortic coarctation, it occurs due to the anatomical narrowing of the lumen of blood vessels. As a result, an increased blood pressure is observed in the arteries extending from the place of constriction. At the same time, hypertension can develop as a result of an increase in the peripheral resistance to blood flow caused by functional narrowing of arterioles and small arteries. It is connected with the infringement of nerve or humoral regulation of vascular tone, as well as the excessive secretion of renin, which participates in the formation of the body pressor substances such as angiotensin. Finally, in the case of endocrine diseases, hypertension occurs due to the vasopressor properties of a number of hormones of the adrenal (namely,epinephrine, aldosterone) and other glands. In this case, some humoral agents (such as adrenaline) affect the cardiac output, contributing to its increase.

At the same time, the age of a patient is among the definitive factors for the development of hypertension. In particular, in the case of essential hypertension, namely its initial stages, its symptoms in patients under the age of 30 years include a lack of reduction in the peripheral vascular resistance in response to exercise. On the other hand, in people without a predisposition to hypertensive disease, this parameter is reduced to meet the needs for the growth of the volume of blood flow velocity in the periphery. At the same time, in elderly patients with essential hypertension, the abnormally high level of peripheral vascular resistance represents a major cause of the blood pressure rise. The disease progresses in the course of ontogeny, becoming moderate or severe on a permanent basis as a consequence of the persistent anomalous increase in the systemic vascular resistance. Moreover, in elderly patients, the minute volume of blood circulation may be pathologically reduced, resulting in a congestive heart failure. Thus, it is clear that with age, the peripheral vascular resistance increases, providing for the development of hypertension.

Genomic Issues

The essential hypertension is known to be developed due to the issues on the genetic level. In particular, in case one of the parents suffers from this disorder, its risk in children increases six-fold in comparison with the risk of hypertension in people, whose relatives do not suffer from such a disease. Among many pathogenic mechanisms that can lead to the development of this disorder, those that mediate its effect through the renin-angiotensin system are among the most significant. They can affect the cardiovascular system not only by vasoconstriction and sodium and water retention, but also due to trophic effects. In particular, renin affects the angiotensinogen (AGT gene) and converts it to angiotensin-1. After that, angiotensin-1 is exposed to the effect of converting enzymes, transforming into a biologically active angiotensin-2, which can either increase or maintain the blood pressure. This protein acts through angiotensin receptor cells. There are two types of receptors, encoded by the AGTR1 and AGTR2 genes. By communicating with them, angiotensin-2 implements its numerous functions. Thus, it plays a crucial role in the pathogenesis of hypertension, affecting vascular smooth muscles and causing their spasm. In its turn, the peripheral resistance increases, often being accompanied by the ventricular hypertrophy.

Additionally, the development of hypertension can be determined by the genetic factors that are responsible for the intracellular transport of ions. In particular, G-protein encoded by the GNB3 gene mediates the transfer of signals into the cell, controlling vascular tone and proliferation of many cell types. The changes in the G-protein activity are associated with vasoconstriction and hypertension, as well as the left ventricular hypertrophy. Moreover, there is a link of genetic marker GNB3 C825T with the development of insulin resistance and obesity, which often accompany hypertension. In its turn, this means that G-protein may contribute to the development of this disorder both in the direct and indirect way. As a result, it is possible to say that hypertension can be of a hereditary nature due to the fact that it can emerge as a result of the genomic issues. Thus, it can be observed not only in the elderly people, but also the younger ones.

Literature Review

The problem of hypertension has become especially acute nowadays due to the significant changes in the lifestyle of people and the lack of information on the causes of its essential form. As a result, it is being addressed in a wide array of scientific works. In particular, the authors focus on the ways of treating this disorder, including the ones that do not involve the use of drugs, as well as those aimed at people suffering from the related diseases. Several authors dedicate their articles to the genetic factors that affect the development of hypertension. In particular, they review the effect of renin on the angiotensinogen, as well as that of the G-proteins on the body cells, making it possible to say that the high blood pressure may be a hereditary disorder. At the same time, the problem of hypertension is reviewed in the specialized guidelines created by the members of the national healthcare organizations, including the American Medical Association and the American Society of Hypertension. These works provide an insight into the algorithm of actions during the treatment of a hypertensive patient. As a result, they serve as valuable sources of information on the types and symptoms of the disease, as well as the ways of its treatment in people belonging to a specific age group. Still, many issues regarding the causes of essential hypertension remain uncovered due to the lack of information on the subject.

Data Gathering

The process of gathering the data for the research paper was based on the approach involving the use of semantic relations, which reflect the connection between different concepts. The search for the relevant scholarly articles was primarily carried out in the medical databases that provide an opportunity of a simultaneous search on several websites. The first of them is PubMed/MEDLINE, which allows searching for the article by its title, contents of the abstract, author’s name, and the name of a journal. Additionally, the data gathering process involved the use of Medbioworld portal, which contains one of the comprehensive collections of links to the sources of professional medical information (journals, professional healthcare associations, dictionaries, nosological databases, and the results of clinical trials). The search was based on the use of keywords, including hypertension, genome, treatment, and symptomatic. The use of semantic relations during this process has allowed establishing the connection between the abovementioned terms, providing the access to several relevant articles that were used in the course of the research.

Approaches to the Treatment

The primary goal of the treatment of hypertension is the prevention of long-term effects of this pathological condition. Most patients require a lifelong antihypertensive therapy, but at first, it is advisable to observe the blood pressure within 4-6 months to assess the possibility of its spontaneous decrease prior to defining the best way to treat the disease. In general, it is possible to define the two approaches to the treatment of hypertension. The first of them is a drug-free treatment, which is based on introducing certain changes in the lifestyle of a patient. In this case, the primary measures include dieting, the reduction in the excess body weight, sufficient physical activity, and avoiding harmful habits. In particular, the diet implies a restriction of salt and free liquid. At the same time, the share of animal fats is to be reduced, with their partial replacement by the vegetable oils. The daily ration of a patient must also include the foods rich in cell walls (vegetables, fruits, and cereals), vitamins, potassium ions, calcium, and magnesium.

At the same time, patients with the excessive body mass encounter additional difficulties in the course of the drug-free treatment. As it was mentioned before, people who suffer from hypertension are often obese. However, in case the weight of a patient exceeds the norm, there is a higher chance of the occurrence of coronary heart disease, diabetes, and atherosclerosis against the background of high blood pressure. In order to reduce the amount of energy stored in the body as fat, one must consume less energy than the amount used by the organism. It is possible to lose weight in three ways: reduce the food intake, increase the physical activity, and combine these two methods. As an independent method of the non-pharmacological treatment of hypertension, as well as an adjunct to diet, a sufficient physical cyclic activity (walking, jogging, and skiing) can help in normalizing the blood pressure. It improves the blood circulation, stimulates the heart and lungs, relaxes joints, and helps to lose weight. Moreover, the repeated dynamic loads of moderate intensity cause a significant decrease in blood pressure, regardless of the weight loss or change in sodium excretion. About a half of the patients at an initial stage of hypertension can counter the effects of this disorder with the help of the non-drug treatment, which makes it rather efficient.

However, in case of the aggravating factors in the patient’s history (namely, hypertensive crises, sudden pressure fluctuations, hypertrophy of the left ventricle of the heart, atherosclerosis, coronary artery disease, severe and malignant hypertension, and death from a cardiovascular disease in the family), the non-pharmacological methods are inefficient. In this regard, it is possible to define another approach to the treatment of hypertension – the drug therapy. Generally, at the initial stage, a single drug is prescribed, with its intake starting from the minimum recommended dose. It is especially crucial to take into account the possible contraindications to the use of certain medications in the individual patients, as well as the possibility of drug correction of the associated risk factors. Most often, the pharmacological therapy involves the prescription of the so-called first-line drugs, namely, the ones satisfying several requirements in the course of their long-term intake. First of all, the medication must not violate the carbohydrate and fat metabolism in the organism. There must also be no delays in the movement of the body fluids. Moreover, after the cancellation of treatment (i.e. the change of the type of drugs), the patient must not experience sharp increases in blood pressure. In addition, the therapy must not affect the content of electrolytes in blood and tissues, as well as not oppress the activity of the central neural system.

The requirements mentioned above narrow the list of drugs that can be used to treat hypertension. As a result, the pharmacological therapy is based on the use the several major drug classes: beta blockers, diuretics, calcium antagonists, ACE inhibitors, blockers of alpha-1-adrenergic receptors and angiotensin-2 receptor blockers. All these drugs have their indications and contraindications, side effects, and characteristic features. Therefore, only a qualified physician can determine the course of therapy and drugs scheme, since a self-medication can lead to negative consequences. It should be noted that the primary aspect of the drug treatment is its continuity. It is imperative not to stop taking the drug abruptly, because, in some patients, even the temporary interruptions in therapy are fraught with severe complications, such as myocardial infarction and cerebral stroke.

Final Approach

By taking into account all the facts provided above, it is possible to say that the drug therapy is the most efficient approach to the treatment of hypertension. The primary reason for such selection is the fact that the non-drug treatment proves to be efficient only during the initial stages of the disease. Moreover, its effects can be observed only in the long-term perspective. Additionally, some of the patients (especially the elderly ones) may be incapable of adhering to a strict diet or dealing with dynamic loads, which narrows the field of use of such approach.

On the other hand, the pharmacological treatment can be used at any stage of the disease. Moreover, as it was mentioned before, there are several major types of drugs that can be used to treat people with hypertension, which means that it is easier to adapt the course of therapy to the needs and peculiarities of a particular patient. As a result, the use of medications proves to be more efficient than the changes in a person’s lifestyle. It should be noted that the results it provides can be improved through the combination of approaches described above. However, such combined therapy is only possible in the case the patient is capable of leading the active way of life and does not have problems with metabolism. Therefore, all these facts justify the selection of the drug therapy as the preferable approach to the treatment of hypertension. At the same time, it must be complemented by the follow-up treatment that will be discussed further.

Follow-Up Treatment

In the case of hypertension, it is essential to begin the follow-up treatment after the start of the pharmacological therapy. The primary purpose of these measures is to bring the blood pressure goal to the normal level, as well as counter the possible negative effects of the certain drugs. After the start of drug therapy, the patient must visit a doctor at least once a month until their blood pressure is normalized. The measures taken during these visits are determined by the types of drugs used in the course of the antihypertensive therapy. In particular, in case the use of beta-blockers should be carried, an electrocardiogram of a patient must be taken on a monthly basis in order to detect any possible changes in the rhythm of the heart. Additionally, it is necessary to control the level of glucose and lipids in the person’s blood. In case of the use of calcium antagonists, the doctor must carry out a regular evaluation of the emotional state of the patient, as well as their muscle tone. On the other hand, diuretics taken in the course of therapy reduce the level of potassium in the blood. Therefore, a continuous monitoring of potassium level, blood sugar, and lipids, as well as the monthly electrocardiogram must be included in the follow-up treatment. Finally, after the blood pressure goal is reached, the physician must be visited each three months to monitor overall state of the patient and define any negative dynamics.

Conclusion

In conclusion, it is possible to say that hypertension, especially the essential one, is a serious disease that can affect not only the older people, but also the youths due to its connection to genomic issues. Moreover, it has a negative effect on the organism as a whole, causing many cardiovascular disorders. Thus, in case of a positive diagnosis, the treatment must be started immediately. The drug therapy should be prioritized due to its efficiency, as well as the fact that it provides more opportunities in terms of the individual approach to the patient. However, its combination with the non-pharmacological treatment can provide the best results, keeping the disease in check for many years. At the same time, the significance of the follow-up treatment is not to be overestimated, since returning the blood pressure to a normal level can be a lengthy process. Moreover, some of the antihypertensive drugs and their combinations may have adverse effects on the human body. As a result, the patient’s condition must be monitored on a constant basis.

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