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Focus on arterial hypertension

  1. Gastroepato
  2. Cardiology
  3. Focus on arterial

notes by dr Claudio Italiano 

For years we have not had valid guidelines about the treatment of hypertensive disease. Recently, the European Society of Arterial Hypertension (ESH) and the European Society of Cardiology (ESC) have begun to outline the treatment of hypertension, with the aim of providing education and recommendations in the difficult field of treatment. of the hypertensive patient.

It is well known that, by measuring the pressure with the manometer, there is a maximum systolic and a minimum or diastolic pressure, which normally should be around <120 mmHg / <80, respectively for systolic and diastolic.

The studies carried out showed that:
Greater importance - is given to the high diastolic pressure, for the purpose of establishing cardiovascular diseases and the onset of stroke;
- The pulsatory pressure (less diastolic systolic), that is identifiable in the difference between maximum and minimum pressure is also responsible for organ damage, which is generally considered "normal", but there are no precise studies, around a maximum of 50 mmHg
- Elevated systolic and diastolic blood pressure values ​​are equally correlated with cardiovascular events, cerebral vasculopathy and renal failure.

What's the right pressure?

In light of the various trials we can give optimal values between 115-110 and 75-70 mmHg, but we are talking about the sex of angels! Then referring to the ESH / ESC guidelines we will say:

sitolic arterial pressure in mmHg - diastolic blood pressure in mmHg

Optimal <120 and <80
Normal 120-129 and / or 80-84
Normal-high 130-139 and / or 85-89

Grade 1 140-159 and / or 90-99 hypertension
Grade 2 hypertension 160-179 and / or 100-109
Grade 3 hypertension> 180 and / or> 110
Isolated sitolic hypertension> 140 and <90

Classification of hypertension and its function

It is necessary, because the doctor starts from these concepts and manages to calculate and stratify the risk of pathological events for the patient. In other words, if I am hypertensive, if I have a maximum pressure> 180 mmHg or a PAD> 110, then with mathematical certainty I will meet renal and cardiovascular disease (CV), that is, the probability that I am getting worse increases. If then the pressure is added to other diseases such as dyslipidemia and diabetes, then the need to keep the lowest possible blood pressure values ​​becomes imperative. Therefore all hypertensive patients should be classified not only on the basis of the degree of arterial hypertension but also on the basis of the overall cardiovascular risk profile, evaluating the presence of risk factors, organ damage and concomitant diseases. Therefore, despite the dosage of drugs and the target set for achieving optimal compensation, appropriate drugs must be prescribed to achieve a further lowering of blood pressure values, which goes beyond the values ​​considered normal if these risk factors aggravate the prognosis. Given the facts, we can state that there are certainly subjects with a high cardiovascular risk with systolic pressure> 180 mmHg and / or diastolic pressure> 100 mmHg, or with a lower systolic pressure, ie 160 mmHg but with diastolic values ​​<70 mmHg, therefore with high pulsation gap. Then there are diabetics and patients with metabolic syndrome and patients who have 3 or more cardiovascular risk factors or one or more markers of subclinical organ damage, as already mentioned above (myocardial hypertrophy confirmed with ecg or with echocardiography, altered diastolic release of the myocardium, which represents a sort of cardiac "decompensation" in nuce, an increase in serum creatinine, microalbuminuria and cardiovascular and renal diseases together) for which the goal is to achieve the lowest possible blood pressure values.

In fact it has been seen that reducing blood pressure by 10 mmHg, the risk of stroke and cardiovascular events is reduced by 25-30%. Then we also saw that some drugs are indicated for the prevention of stroke, for example calcium antagonists (amlodipine, nifedipine,), while ACE inhibitors (ramiprilat, enalapril, lisinopril) for coronary heart disease, for hypertrophy of infarction; the sartans are also excellent, for example in patients with proteinuria (candesartan has been compared to enalapril), excellent for myocardial hypertrophy, also indicated in patients with atrial fibrillation.

Factors that influence the prognosis in the already hypertensive patient

- Systolic and diastolic high blood pressure
- Pulsating pressure
- Age> 55 years for males and> 65 years for women
- Smoking habit
- Dyslipidaemia: total cholesterol> 190 mg%; C-LDL> 115 mg%; C-HDL <40 mg% for males and 46 for females; Triglycerides> 150 mg%
- Fasting blood glucose> 125 mg%
- Altered load blood sugar (see diabetes)
- Abdominal obesity with waist circumference> 102 for males and> 98 cm for females (see Belly and hips: metabolic syndrome Belly and hips = risk of heart attack and stroke!) Food Pyramid Obesity Day October 10: diet right)

- Familiarity for early CV diseases
- Diabetes mellitus with fasting plasma glucose> 126 mg% and post-prandial> 198 mg%
- Subclinical organ damage
- Evidence of hypertrophy of the myocardium both at the ECG with Sokolow-Lyon index> 38 mm
- Thickening of the carotid wall> 0.9 mm or atheromatous plaques
- Carotid-femoral pulse wave velocity> 12 m / s
- Press index ie lower / upper limb pressure ratio <0.9
- Plasma creatinine increase 1.3-1.5 and females 1.2-1.4 mg%
- Reduction of the glomerular filtrate <60 ml / min
- Microalbuminuria 30-300 mg / 24 hours
- CV or renal disease established in the diabetic
- Cerebrovascular diseases: ischemic stroke, hemorrhagic or transient ischemic attack
- Heart diseases: myocardial infarction, angina, coronary revascularization, heart failure
renal diseases: diabetic nephropathy, renal failure, proteinuria> 300 mg / 24 hours
- peripheral vasculopathy
- advanced retinopathy: haemorrhages or exudates and papilledema

Pressure, when to cure?

The treatment of blood pressure must take into account many factors, to be conducted more or less incisively.

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