Differential diagnosis of Arterial Hypertension The World Health

Differential diagnosis of Arterial Hypertension The World Health Organization’s criterion for the definition of hypertension is arterial hypertension more than 140/90 mm Hg.

Definition Symptomatic arterial hypertension is secondary to diseases or lesions of the organs (or systems) involved in regulation of arterial pressure. The incidence of symptomatic hypertension is 10-12 per cent of all patients hospitalized for elevated arterial pressure.

Assessment of patients. During the assessment period it is necessary: to establish the fact of high arterial pressure, to suggest primary or secondary hypertension. Secondary causes of hypertension should be excluded, the target-organ effect of the blood pressure should be evaluated, and any concomitant conditions (dislipidemia or diabetes) should be identified.

Classification. I. Renal (nephrogenic) hypertension. II. Endocrine hypertension. III. Hypertensions due to lesions of the heart and large arteries (haemodynamic hypertension). IV. Neurogenic (due to organic lesions of the nervous system). V.Drug induced hypertension

Clinical picture of SAH Clinical picture is characterized by the symptoms associated with elevated BP and the symptoms of underlying disease

High BP causes headache, vertigo, spots before the eyes, noise in the ears (tinnius), pain in the heart. Stable AH is manifested by hypertrophy of the left ventricle, accentuated second sound over the aorta, the changes in the optic fundus. The symptoms of underlying disease can be marked by the clinical picture of the main disease or be absent

The symptomatic character of AH is suggested by the following: development of AH in young patients and in aged over 50-55; acute onset and rapid stabilization of BP at high values; asymptomatic course of AH; resistance to hypertensive therapy; malignant course of AH; The variability of the clinical picture is explained by the great number of diseases.

Diseases of the kidneys, examinations confirmed the diagnosis Diseases of renal parenchyma: Exam. Confirmed: Chronic glomerulonephritis Biopsy of kidneys Chronic pyelonephritis Excretory urography Interstitial nephritis Biopsy of kidneys Amyloidosis Biopsy of kidneys Polycystic kidney Sonographic scan Renal tumor Sonographic scan Angiography, CT

Renovascular diseases Fibromuscular hyperplasia of renal arteries Atherosclerosis of the renal arteries Thrombosis and embolism of the renal arteries, Abnormal renal arteries Examinations confirmed the diagnosis: Excretory urography Angiography

Diseases associated with occlusion of the urinary ducts: pyelonephritis superimposed upon urolithiasis, obstructive uropathies, congenital defects such as hydronephrosis, hypoplastic or dystopic kidney, hypermobile kidney, abnormalities of development and position of the kidney ducts. Examinations confirmed the diagnosis: Excretory urography

Obligatory examinations 1. Electrocardiography 2. Chest X-ray 3. Studies of the optic fundus 4. Excretory urography 5. Blood analysis: total blood counts, urea, creatinine, cholesterol, triglycerides, sugar, protein and its fractions 6. Studies of the urine, determination of formed blood elements Nehiporenko`s test), test for daily variation of specific gravity (Zimnitsky`s test), determination of daily proteinuria, bacteriuria, qualitative studies on leucocytes.

Examinations for special indications 1. Quantitative estimation of bacteriuria, daily protein excreted with urine, 2. Total testing of the renal function, 3. Testing the function of each separate kidney (radionuclide renography and scanning, infusion and retrograde pyelography, chromocytoscopy), 4. Sonographic scanning of the kidneys, 5. Computed tomography of the kidneys, 6. Contrast angiography (aortography with estimation of the renal blood flow and cavography with phlebography), 7. Testing blood for the renin and angiotensin content.

Endocrine diseases: 1. Pheochromocytoma and pheochromoblastoma; 2. Aldosteronoma (primary aldosteronism or Conn's syndrome), 3. Itsenko-Cushing's syndrome and disease, 4. Acromegaly, 5. Diffuse and toxic goiter.

Examinations confirmed the diagnosis: 1. Determining daily excretion of catecholamines with the urine and in blood during attac; Computed tomography (CT) 2. Determining aldosterone and renin in the blood . CT (to reveal tumors) 3. Determining 17-hydroxycorticosteroids in daily urine and daily secretion into the blood. CT (to reveal pituitary adenoma) 4. Computed tomography 5. Determining of the hyperfunction of the gland

Diseases of the heart, aorta and large vessels: Acquired heart diseases (aortic insufficiency), Congenital heart defects (patent arterial duct); Diseases of the heart attended by congestive failure Complete atrioventricular block; Congenital defects of the aorta (coarctation) Acquired diseases (arteritis of the aorta and its branches, atherosclerosis); Stenosed carotid and vertebral arteries.

Examinations confirmed the diagnosis: Angiography Sonographic scanning Computed tomography

Diseases of the central nervous system: Tumour of the brain Encephalitis Trauma Focal ischaemic lesions Examinations confirmed the diagnosis: Neurological examination Sonographic scanning Computed tomography

General measures 1. Weight reduction 2. Reduction of heavy alcohol intake and smoking. 3. Salt restriction 4. Regular exercise.

Drug treatment The aim of drug treatment to reduce the risk of complications of EH. The British Hypertension Society recommends the initiation of drug therapу in follow. cases: if the diast. BP exceeds 100 mmHg and more if there is evidence of target - organ damage оr if there are other risk factors (e g diabetes) or if the patient is above 60 years of age. if the patient has a persistent syst. BP above 160 mmHg.

Diuretics. Thiazide diuretics: Hydrochlorthiazidum (Hypothiazidum, Esidrexum) 12, 5-50mg Bendrofluazide 2, 5 -5 mg Cyclopenthiazide 0,25-5mg Diuretics as thiazide: Indapamid (Arifon) 2,5mg Chlortalidonum 12,5 - 25mg Xypamid 20-40mg Loop diuretics: Furosemidum (Lasix) 20-60mg Potassium-sparing diuretics: Triamterenum 25-100 mg Spironolactonum (Aldactonum) 25-200 mg

The mechanism of action of diuretics: Decrease of volume of a circulating and extracellular liquid Decrease of cardiac output during long application Direct dilatation

Indications to using diuretics: Heart failure AH in advanced age Systolic AH Possible indications to using diuretics: Diabetes Osteoporosis Contraindications to using diuretics: gout

Contraindications to using diuretics Gout Possible contraindications to using diuretics: Dislipidemia (in high doses) AH at sexly active men (in high doses) Diabetes (in high doses) Renal failure (potassium-sparing diuretics) Hepatic coma

Side effects of diuretics: Hypokalemia, Hypomagnesiemia, Hyponatremia, Hypocholiemia, Hyperuricemia, Hyperglycemia, Nitrogenemia, Hypercalcemia, Impotency, Orthostatic hypotension, Metabolic alkalosis, The secondary hyperreninemia and hyperaldosteronism, Dermatitis, pancreatitis, vasculitis

β-blockers Blocking β1-receptors (selective): With sympathomimetic activity: Acebutolol 200 mg, Talinololum; Without sympathomimetic activity: Atenolol 100 mg, Metoprolol 50-400mg, Blocking β1-and β2-receptors (not selective): With sympathomimetic activity: Oxprenololum 20-80 mg, Pindololum 5-15mg, Without sympathomimetic activity: Anaprilin 100 mg, Timololum, Sotalol, Nadololum 480mg. Blocking β1- both β2 - receptors and α1-receptors: Labetolol 200-600 mg, Carvedilol 12,5-50mg.

The mechanism of antihypertensive action: Decrease rate of the heart and cardiac output Decrease the contractility of the heart Blockade of a secretion of a renin The central oppression of a sympathetic tone Blockade postsynaptik peripheric β-adrenoreceptors. Rising of a level of prostaglandinums in a blood Rising of baroreceptor sensitivity

Indications to using β- adrenoblockers: Angina pectoris, Myocardial infarction in anamnesis, Tachyarrhythmias, Heart failure Possible indications: AH in pregnant Diabetes Migraine Preoperative AH Hyperthyroidism Essential tremor

Contraindications to using β- adrenoblockers: Chronic obstructive diseases of the lungs Atrioventricular blockade of 2-3 degrees Possible(probable) contraindications to using β -blockers: Dislipidemia AH at sportsmen and in physically active persons Diseases of peripheric vessels Depression

Side effects: Deterioration a lipide profile of a blood. Dicrease of sensitivity for an insulin. Possible deterioration of current chronic obstructive diseases of the lungs, a heart failure and diseases of peripheric arteries. A potentiation hypoglycemic effects of antidiabetic agents. The central effects: a sleeplessness, dreadful dreamings. Subjective side effects with refusing of treatment

Angiotensin-converting enzyme inhibitors: Drug inithial dose, mg maint. dose, mg Captopril 25 -75 50-150 Benezepril 2-5 5-10 Enalapril 10-20 40 Lisinopril 10 20-40 Perindopril 2 5-10 Ramipril 1,25-2,5 5 Cilazapril 2,5 5

The mechanism of antihypertensive action of ACE-inhibitors: Direct elimination of a vasoconstriction. Dicrease of a secretion of aldosteronum, resulting in to elimination of a vasoconstriction, decrease a delay of a sodium and water. Activation of kallykrein-kinin system Decrease formation (education) of vasoconstrictors and antynatriyuretic substances (noradrenalinum, arginine - vasopressinum, andothelin-1) Improvement the function of the endothelium, resulting to release of oxide of nitrogen.

Indications to using ACE-inhibitors: Heart failure Dysfunction of a left ventricle The myocardial infarction in anamnesis Diabetic nephropathy Possible (probable) indications to using ACE-inhibitors: Renal failure Contraindications to using ACE-inhibitors: Pregnancy Hyperkalemia Bilateral stenosis of renal arteries

Side effects ACE-inhibitors: Hypotension of the first dose Nitrogenemia, decrease of kidney function Hyperkalemia Dry tussis Quincke's edema Disturbance of a taste Leukopenia Dermal eruption Dyspepsia

Calcium channel blockers Phenilalkilamines: Verapamilum 40-480 mg (Isoptinum, Finoptinum) Dihydropyridines: Nifedipinum (Corinfar, Cordaphen) 10-40 mg Nifedipinum retard 20-40 mg Nitrendipin 10-20 mg Amlodipin 2,5-10 mg Phelodipin 7,5-10 mg Isradipin 5-15 mg Nicardipin 5-90 mg Lisidipin 2-6 mg Benzothiazepines: Diltiazem 180-100 mg

The mechanism of action of calcium channel blockers Decrease peripheral vascular resistance due to the expressed arterial vasodilation owing to an inactivation of a current of ions of calcium through potential dependent channels (L, N, R, T ) a vascular wall. Decrease of cardiac output due to negative inotropic and chronotropic action.

Indications to using calcium channel blockers: Angina pectoris AH in old age Systolic AH Possible (probable) indications to using calcium channel blockers: Diseases of peripheral arteries Migraine (not dihydropyridines) Tachyarrhythmias (not dihydropyridines) Myocardial infarction (not dihydropyridines) Diabetes with a proteinuria

Contraindications to use calcium channel blockers: Decrease of heart conduction (Verapamilum and Diltiazem at atrioventricular blockade of 2-3 degrees) Possible (probable) contraindications to using calcium channel blockers: Heart failure (not dihydropyridines)

Side effects of antagonists of calcium: The effects due to vasodilation (mainly dihydropyridines): peripheral eodema, a headache, a giddiness, flushing of face, palpitation, a hypotension . The effects due to negative chronotropic, inotropic-, and dromotropic effect (mainly Verapamil and Diltiazem): intensifying of a heart failure, dicrease of a-v conduction. Action on alimentary tract: constipations, a diarrhea, a vomiting (Verapamil at old patients is more often)

α - adrenoblockers 1. Non selective α - adrenoblockers: Tropodiphenum (Tropaphenum) (M - cholinolytic action), Phenoxybenzamine, Phentolaminum 2. Selective α1-adrenoblockers: Doxazin 1-16 mg, Prazozinum 5-20 mg, Terazozin 5 – 10 mg, 3. Drugs with α1-аdrenoblocker action: Dihydroergotoxin (an agonist DA - receptors), Droperidolum (neuroleptic), Carvedilol (α-, β - adrenoblocker), Cetanserin (a blocker of peripheral S2-serotonin receptors), Labetolol (α-, β - adrenoblocker)

The mechanism of action selective α - adrenoblockers: block action of Noradrenalinum on receptors of arterioles Indications to use α - adrenoblockers: Benigin hypertrophy of prostatic gland. Possible (probable) indications to using α - adrenoblockers: Hypertryglicerinemia, Dislipidemia Possible (probable) contraindications to use α - аdrenoblockers: Orthostatic hypotension Heart failure.

Side effects: Necessity to select a dose in connection with hypotension caused by the first dose. Subjective dose limiting effects

Blockers of АТ1-receptors 1. Inactive drugs: Lozartan 50 - 100 mg, Candesartan 4 - 16 mg, Tazocartan. 2. Active medicinal substances: Valsartan 80 - 320 mg, Irbesartan 150 - 300, Telmisartan 40 - 80 mg, Eprosartan 400 - 800 mg.

The mechanism of antihypertensive action of blockers of АТ1-receptors: selective elimination of effects of angiotensin II, prodused through АТ1-receptors Indications to use blockers of АТ1-receptors: Intolerance for ACE-inhybitors (tussis) Possible (probable) indications to use of blockers of АТ1-receptors: Heart failure.

Contraindications to use of blockers АТ1-receptors Pregnancy, Hyperkalemia, Bilateral stenosis of renal arterias. Side effects The side effects are the same ACE-inhibitors, but frequency is less often.

Drugs of the central action Drugs of a first generation agonists of the central α2-adrenoreceptors (Methyldopa, Clonidinum). Drugs of a second generation - agonists I1-imidasol receptors: Moxonidin, Rilmenidin.

Pharmacological effects of agonists I1-imidazol - receptors: Activity of sympathetic nervous system is decreased. A tone of a vagus nerve is rised. Decrease reabsorbation of sodium and water in proximal channels of kidneys. Decrease peripheral resistence and cardiac output. Decrease of releasing of catecholamins. Intensifying of a lipolysis. Often side effects (a sleepiness, dryness in a mouth).