Arterial hypertension

Arterial hypertension is defined by the value of arterial pressure in which medical treatment has been shown to outweigh the potential harm. According to large randomized clinical studies, the values of ambulatory measured systolic pressure are ≥140 mmHg and / or diastolic ≥90 mmHg.

Arterial hypertension


Cardiovascular risk and arterial hypertension

Measurement and Classification of Arterial Pressure

Masked hypertension and white collar hypertension – “White Angle Syndrome”

Treatment of patients

Treatment of arterial hypertension

Resistant and secondary hypertension

In 2015, as many as 1.13 billion people were estimated to be suffering from hypertension, and it is estimated that by 2025, one third of the world’s population will suffer from arterial hypertension, partly due to an aging population but also a significant increase in world-wide obesity. The high incidence of patients with arterial hypertension extends across the globe, regardless of the level of development of individual countries.

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Cardiovascular risk and arterial hypertension

Less than 50% of treated patients have a regulated pressure below 140/90 mmHg.

Arterial hypertension is a major independent risk factor for cardiovascular morbidity and mortality. The term cardiovascular disease refers to diseases of the heart and blood vessels, most caused by atherosclerosis, and includes: coronary disease (eg heart attack), cerebrovascular disease (eg stroke) and peripheral arterial disease are the leading causes of mortality and disability in the world. The constant increased pressure on the arterial walls in arterial hypertension weakens the walls and makes them susceptible to atherosclerotic damage. Arterial hypertension is also called a “silent killer” because, if not diagnosed and treated, it causes damage to the target organs – blood vessels, heart, brain and kidney. Despite the availability of therapy, the control of treated hypertensives is unsatisfactory. Less than 50% of treated patients have a regulated pressure below 140/90 mmHg. It is well known that treatment can lead to the recovery of certain target organ damage or their progression may be slowed.

Measurement and Classification of Arterial Pressure

Proper pressure measurement is done after 5 minutes of sitting with your back supported and your heart level arm.

Measurement of arterial pressure is a thorough examination in the diagnosis and stratification of patients with arterial hypertension, and it is crucial when deciding on the beginning and method of treatment and monitoring of patients, so it is important to properly measure arterial pressure.

Considering the measured values of arterial pressure in the office, arterial pressure is classified as optimal (<120 mmHg systolic and <80 mmHg diastolic), normal (120-129 mmHg systolic and 80-84 mmHg diastolic), high-normal (130-139 mmHg systolic and / or 85-89 mmHg diastolic), 1st degree hypertension (140-159 mmHg systolic and / or 90-99 mmHg diastolic), 2nd degree hypertension (160-179 mmHg systolic and / or 100-109 mmHg diastolic) ), Grade 3 hypertension (≥180 mmHg systolic and / or ≥110 mmHg diastolic), and isolated systolic hypertension (≥140 mmHg systolic and <90 mmHg diastolic).

Proper pressure measurement is done after 5 minutes of sitting with your back supported and your heart level arm. Initial measurements should be carried out on both hands and if there is a significant difference in the measured pressure values, it is recommended that subsequent measurements be carried out on the arm where multiple values were measured. A significant pressure difference is above 20 mmHg systolic and 10 mmHg diastolic pressure and the patient should then be referred for further treatment.

The most common causes of an incorrectly obtained blood pressure measurement result are:

inaccuracies before measurement (immediate meal, consumption of alcohol and coffee, full bladder, exposure to cold, fatigue after physical exertion)

improper selection of pressure gauges (non-validated and un calibrated device)

patient position (standing or lying down instead of sitting, legs crossed, back unsupported, unsupported arm, arm placed below heart level)

position of the device on the patient (paretic arm, arm with arterioscopic fistula, too small or too large arm, band wrapped over clothing)

during measurement (white cloak effect, talk during measurement, use of bells, not diaphragms of stethoscope, excessive pressure with stethoscope, rapid release of air from the collar, hearing impaired meters, short period between measurements)

interpretation of measurement results (confidence in only one measurement, variability between hands, rounding of values).

In addition to aberrant arterial pressure measurement, home self-monitoring arterial pressure (MATS) and continuous arterial blood pressure (KMAT) measurements are also used.

Home blood pressure measurement is subject to the same rules as for office measurement and the use of a wrist pressure gauge or finger measurement is not supported. It is necessary to measure blood pressure 6-7 days in a row with two measurements in the morning and two measurements in the evening and cigarettes and caffeine should be avoided 30 minutes before the blood pressure is measured. The mean blood pressure should be calculated and the definition of hypertension for home measurement is ≥135 / 85 mmHg.

A 24-hour arterial blood pressure (KMAT) device is also in use, with the device measuring blood pressure every 15-20 minutes during the day and every 30 minutes during the night. During the 24-hour recording, the patient performs his usual daily activities, but according to the oscillometric method , strenuous activity and holding heavy objects in the arm at which blood pressure is measured should be avoided, and the arm relaxed and stretched at the time of measurement. For the best interpretation of the data, it is necessary to keep an activity log during the 24-hour measurement and indicate the duration and quality of sleep. The limit values for the definition of hypertension at KMAT are above ≥130 / 80 mmHg for 24 hours, ≥135 / 85 mmHg for daytime average and ≥120 / 70 mmHg for nighttime average.

Masked hypertension and white collar hypertension – “White Angle Syndrome”

Masked hypertension is a clinical entity in which patients with elevated arterial pressure are recorded at home, while normotensive values are measured in the office. Masked hypertension is associated with an increased risk of target organ damage in hypertension, and lifestyle changes and regular monitoring are certainly recommended, and pharmacological treatment is not yet fully defined, so further research is needed.

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White collar hypertension is a clinical entity with elevated blood pressure readings in the office and normotensive with KMAT and MATS. It is also associated with increased cardiovascular risk. As a therapeutic measure, it is recommended to change life habits, then more frequent monitoring, and pharmacological treatment is not fully understood.

Treatment of patients

In the treatment of patients with arterial hypertension it is necessary to: take a detailed family and personal history, perform a physical examination, evaluate the overall cardiovascular risk and damage to the target organs (heart, blood vessels, brain, kidney, eyes), and, if necessary, screen for secondary hypertension .

In the treatment of hypertension, ECG and laboratory findings (CCS, glucose, lipidogram, electrolytes, creatinine, urea, liver enzymes and urine) should definitely be done. Further processing should be planned depending on the findings made, history and clinical status (ultrasound of the heart, ergometry, ultrasound of the abdomen, etc.)

Treatment of arterial hypertension

Treatment should be started in patients with second and third degree hypertension and in those with first stage if there is damage to the target organs or high cardiovascular risk

Treatment for arterial hypertension can be both non-pharmacological (lifestyle change) and pharmacological. The therapeutic goal is to lower the arterial pressure <140/90 mmHg, and in those who are well tolerated, the arterial pressure is also sought to reduce to <130/80 mmHg, with systolic pressure values <120 mmHg not desirable. In patients over 65 years of age, it is recommended that systolic pressure be maintained between 130 and 140 mmHg.

Changing your lifestyle means:

reduction of salt intake to less than 5 g daily (average daily salt intake in Croatia is 11.3 g)

alcohol intake limit, weekly recommendation is less than 14 units for men and 8 units for women (one unit is 125 ml of wine, 250 ml of beer), avoid drinking

increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil) and reduced consumption of red meat and saturated fatty acids (modeled on the Mediterranean diet)

weight reduction, avoiding obesity and body mass index (BMI) above 30 and waist circumference above 102 cm in men and 88 cm in women; Ideally, maintaining a BMI of 20-25 kg / m2 and reducing waist circumference of <94 cm for men and <80 cm for women

Regular physical activity (30 minutes of moderate aerobic activity 5 – 7 times a week)

smoking cessation.

There are 5 major classes of antihypertensive drugs in pharmacological treatment: angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin receptor antagonists (ARBs), diuretics, calcium channel blockers, and beta blockers.

According to the latest European guidelines, pharmacological therapy should be initiated in patients with second- and third-degree hypertension and in those with first-stage disease if target organ damage or high cardiovascular risk exists.

It is recommended that therapy be started with a combination of two medicines with one tablet containing two medicines. An exception is elderly patients and those with a first degree of hypertension and a low risk of starting therapy with a single drug. The most preferred combinations are ACE inhibitors or ARBs in combination with calcium channel blockers or diuretics.

If satisfactory blood pressure control is not achieved, a third drug (typically a combination of ACE inhibitors or ARBs, diuretics, and calcium channel blockers) is recommended. In resistant hypertension, spironolactone is added to said triple therapy or, if not tolerated, a beta or alpha blocker is added.

If there is an indication for taking beta-blockers (coronary artery disease, heart failure, need for antiarrhythmic therapy), an initial combination of beta-blockers with someone else in the group of major antihypertensives is recommended. The combination of ACE inhibitors and ARBs is not recommended.

Resistant and secondary hypertension

Resistant hypertension refers to the inability to adequately control arterial pressure (lowering <140/90 mmHg) with at least three classes of antihypertensives (typically including diuretic, ACE inhibitor, and calcium channel blocker), and inadequate arterial pressure values are documented by MATS or KMAT- om.

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Secondary hypertension refers to that hypertension that has a specific cause that can be treated, and screening for secondary hypertension is performed in specific groups of patients (eg, younger than 40 years, acute exacerbations of otherwise normotensive patients, grade 3 hypertension, suspected obstructive sleep apnea, pheochromocytoma or endocrinological causes, etc.). Secondary hypertension can also be caused by some drugs, such as non-steroidal antirheumatics or corticosteroids.

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