Diagnosis and treatment of hypertension in clinicians


Expert introduction:
Professor Wang Jun, associate professor of cardiology at the Second Xiangya Hospital of Central South University, graduated from Xiangya School of Medicine, Central South University, focusing on intracardiac electrophysiology and pacing.He is good at interventional therapy for arrhythmia and clinical diagnosis and treatment of hypertension, coronary heart disease and heart failure.He has edited many academic monographs, published more than 20 papers at home and abroad, and trained many graduate students.With the progress of the times, people’s health requirements are higher, and the rate of medical treatment is also increasing. In the process of increasing the age, the prevalence of hypertension is also increasing. Next, we will understand the high from several aspects.blood pressure.First of all, we need to understand what is high blood pressure?Hypertension refers to the increase in systemic arterial blood pressure (systolic and/or diastolic blood pressure) (systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg), which may be associated with the function of organs such as heart, brain and kidney.Or clinical syndrome of organic damage.Hypertension is the most common chronic disease and the most important risk factor for cardiovascular and cerebrovascular diseases..So why do you have high blood pressure?At present, it is believed that essential hypertension is caused by a variety of acquired environmental factors in a certain genetic background, which makes the normal blood pressure regulation mechanism decompensated.It is generally believed that genetic factors account for 40% and environmental factors account for about 60%.1. Genetic factors: About 60% of hypertensive patients have a family history.The inheritance of hypertension may exist in two ways: major gene dominant inheritance and multi-gene associated genetics.In terms of genetic phenotype, not only the incidence of elevated blood pressure is hereditary, but also in terms of blood pressure, complications, and other related factors (such as obesity).2. Mental and environmental factors: (1) Diet: Epidemiological and clinical observations show that salt intake is positively correlated with the occurrence of hypertension and blood pressure.Excessive salt intake leads to an increase in blood pressure mainly in salt-sensitive people. Low-potassium diet, heavy drinking, and excessive intake of saturated fatty acids can increase blood pressure.Smoking can accelerate the process of atherosclerosis and is a risk factor for hypertension.(2) Mental stress: People can cause high blood pressure under mental stress, stress, anxiety or long-term environmental noise, and visual stimuli. Therefore, workers with high mental stress and long-term noise environment suffer from high blood pressure.(3) The effects of drugs: contraceptives, hormones, anti-inflammatory painkillers, etc. can affect blood pressure.(4) Other factors: Obesity is an important risk factor for elevated hypertension.The body mass index (BMI) is generally used to measure the degree of obesity, that is, body weight (kg) / height (m) 2 (with a normal range of 20 to 24).There was a significant positive correlation between blood pressure and BMI.3. Effects of other diseases Obesity, diabetes, sleep apnea hypopnea syndrome, thyroid disease, renal artery stenosis, renal parenchymal damage, adrenal space occupying lesions, pheochromocytoma, and other neuroendocrine tumors.There are many factors affecting blood pressure, which are mainly determined by the hemodynamics and the peripheral vascular resistance of the systemic circulation.From this perspective, the pathogenesis of hypertension mainly lies in the following links: 1. Hyperactivity of the sympathetic nervous system: various etiological factors cause changes in the function of the central nervous system of the cerebral cortex, and various neurotransmitter concentrations and activities are abnormal, resulting inThe sympathetic nervous system is hyperactive, the plasma catecholamine concentration is increased, and the resistance of the arterioles is increased.2. Renal sodium retention: various causes of renal sodium retention, the body to avoid increased cardiac output, tissue over-perfusion, systemic resistance of small arterial contraction, resulting in increased peripheral vascular resistance.3. Renin-angiotensin-aldosterone system (RAAS) activation 4. Cell membrane ion transport abnormalities 5. Insulin resistance clinical manifestations The symptoms of hypertension vary from person to person.Early symptoms may be asymptomatic or the symptoms are not obvious. Even after physical examination, blood pressure is increased. A few patients are found after complications such as heart, brain and kidney. Common symptoms are dizziness, headache, tightness of the neck, fatigue,Heart palpitations, tinnitus, etc.Blood pressure rises only after fatigue, stress, and mood swings, and returns to normal after a break.As the disease progresses, the blood pressure continues to rise, and various symptoms gradually appear.This is called slow-onset hypertension.Common clinical symptoms of slow-moving hypertension include headache, dizziness, inattention, memory loss, limb numbness, nocturia, palpitations, chest tightness, and fatigue.The symptoms of high blood pressure are related to blood pressure levels. Most of the symptoms can be aggravated after stress or fatigue. After morning activities, blood pressure can rise rapidly, and early morning hypertension can occur, leading to cardiovascular and cerebrovascular events occurring in the early morning.When the blood pressure suddenly rises to a certain extent, there may even be symptoms such as severe headache, vomiting, palpitations, dizziness, etc. In severe cases, unconsciousness and convulsions may occur, which is a critically ill type of hypertension and critically ill hypertension.Serious damage to the heart, brain, kidney and other organs, such as stroke, myocardial infarction, renal failure, etc.The clinical manifestations of secondary hypertension are mainly related to the symptoms and signs of primary disease, and hypertension is only one of its symptoms.The increase in blood pressure in patients with secondary hypertension may have its own characteristics. For example, hypertension caused by aortic coarctation may be limited to one limb; the increase in blood pressure caused by pheochromocytoma is paroxysmal.The current diagnostic criteria for hypertension in Europe and America are not uniform. The 2017 ACC/AHA hypertension is newly defined as ≥ 130/80mmHg 2018 ESH/ESC for the definition and classification of hypertension, which is unchanged from the 2013 guidelines: defined as the office blood pressure SBP ≥ 140 and / orDBP≥90mmHg, the European guidelines for the diagnosis of blood pressure outside the clinic, especially for home blood pressure monitoring, the 24-hour ambulatory blood pressure average ≥130/80mmHg or the family self-test blood pressure ≥135/85mmHg can diagnose hypertension.At present, the diagnosis of hypertension in China adopts the standard recommended by the guidelines for prevention and treatment of hypertension in China in 2018. Based on the characteristics of Chinese people, it can be summarized as 4 points: 1. The diagnostic criteria remain unchanged, and still maintain ≥140/90mmHg.2. The treatment goal is not much different from the old guide.3. Add cardiovascular risk stratification, include 130-139/85-89 mmHg in the cardiovascular risk level stratification table, include homocysteineemia as a risk factor for hypertension, and include atrial fibrillationIn the case of heart disease in risk stratification, diabetes is divided into two categories: “new diagnosis” and “untreated”, and CKD is involved in different stages to participate in risk stratification.4. The treatment strategy, clear time to meet the standard: 4 weeks to 12 weeks, the initial drug treatment recommendation is more positive (drug starting dose, blood pressure ≥ 140/90 mmHg can be considered combined treatment) cardiovascular risk in patients with elevated blood pressureThe reason why horizontal stratification is to stratify cardiovascular risk in patients with hypertension, especially in normal high-value groups, directly determines the next treatment plan for the patient.The following is a recommendation for the 2018 ESC/ESH Hypertension Guidelines, specifically referring to patients at very high risk for normal high blood pressure, especially in patients with coronary heart disease.In general, the diagnosis of hypertension is relatively simple, as long as the clinician and the patient pay enough attention and close monitoring, they can be diagnosed.The timing of antihypertensive drug therapy depends on the level of cardiovascular risk assessment. On the basis of lifestyle improvement, patients with blood pressure still exceeding 140/90 mmHg and/or target level should be given medication.For patients at high risk and high risk, antihypertensive medication should be started promptly, and combined risk factors and combined clinical diseases should be comprehensively treated. For intermediate-risk patients, it can be observed for several weeks to assess target organ damage and improve lifestyle.If the blood pressure is still not up to standard, the drug treatment should be started. For low-risk patients, the patient can be observed for 1-3 months, followed closely, and the blood pressure monitoring outside the clinic can be performed as much as possible to assess the target organ damage and improve the lifestyle.If the blood pressure is still not up to standard, antihypertensive medication can be started.(A) treatment of essential hypertension 1. The purpose and principle of treatment The main goal of hypertension treatment is to achieve high blood pressure standards, to minimize the incidence of heart and cerebrovascular disease in hypertension patients and mortality.Antihypertensive therapy should establish a target for blood pressure control.On the other hand, hypertension often coincides with other risk factors for heart and cerebrovascular diseases, such as hypercholesterolemia, obesity, diabetes, etc., which synergistically aggravate the risk of cardiovascular disease, and the treatment should be comprehensive.Different people have different antihypertensive targets. The general patient’s antihypertensive target is below 140/90mmHg. For high-risk patients with diabetes or nephropathy, they should be lower as appropriate.For all patients, regardless of whether the blood pressure at other times is higher than the normal value, attention should be paid to the monitoring of morning blood pressure. Studies have shown that more than half of the patients with blood pressure in the office have not reached the standard in early morning blood pressure.(1) Improve life behavior: 1 Reduce and control weight.2 reduce sodium intake.3 supplement calcium and potassium salts.4 reduce fat intake.5 increase exercise.6 quit smoking, limit drinking.7 Reduce mental stress and maintain a psychological balance.(2) individualization of blood pressure control standards: due to different causes, the pathogenesis of hypertension is not the same, clinical medications are treated separately, and the most suitable drugs and doses are selected to obtain the best therapeutic effect.(3) Synergistic control of multiple cardiovascular risk factors: Although blood pressure is controlled within the normal range after antihypertensive therapy, various risk factors other than elevated blood pressure still have an important impact on prognosis.2. Antihypertensive drug treatment For patients with hypertension detected, the recommended starting and maintenance treatment of antihypertensive drugs, especially once a day can control 24 hours and meet the standard drug, because most patientsThe combination of treatment is required to achieve high blood pressure, so the 2018 China Guidelines for the Prevention and Treatment of Hypertension are more recommended for combination therapy, high-risk patients with blood pressure ≥160/100 mmHg, higher than target blood pressure 20/10 mmHg, or high single-agent treatment failure.Patients with blood pressure should be treated with combined antihypertensive therapy, including free combination or monolithic combination; for patients with blood pressure ≥ 140/90 mmHg, small dose combination therapy can also be initiated.(1) At present, the first-line antihypertensive drugs are still five types of diuretics.2 beta blockers.3 calcium channel blockers.4 angiotensin converting enzyme inhibitor.5 angiotensin II receptor blockers.Single or combined use should be selected based on the patient’s risk factors, target organ damage, and clinical disease.The principles for selecting antihypertensive drugs are as follows: 1) Using a half-life of 24 hours or more, once a day, can control 24 hours of blood pressure drugs, to avoid poor control of iatrogenic early morning blood pressure caused by improper treatment options; 2) safe useLong-term adherence and control of each 24-hour blood pressure drug, especially compound preparations, to improve the patient’s treatment compliance; 3) use of heart and brain benefit clinical trial evidence sufficient and can really reduce long-term cardiovascular and cerebrovascular eventsReduce cardiovascular and cerebrovascular events and improve the quality of life of patients with hypertension.(2) Treatment options Most uncomplicated or comorbid patients can be used alone or in combination.In clinical practice, patients with cardiovascular risk factors, target organ damage, complications, comorbidities, antihypertensive effects, adverse reactions, etc., will affect the choice of antihypertensive drugs.Grade 2 hypertensive patients can start with a combination of two antihypertensive drugs.In recent years, the clinical application of long-acting antihypertensive drugs has increased.These drugs have several advantages, such as long-lasting antihypertensive effect, once-a-day medication, stable blood pressure, and less significant blood pressure fluctuations.Another feature of this type of drug is that it has a slow onset of action. It takes about two weeks to take full advantage of the antihypertensive effect, so as to avoid a rapid decrease in blood pressure in a short period of time.For patients with severely elevated blood pressure, advanced age, or severe cardiovascular and cerebrovascular diseases, rapid decrease in blood pressure in a short period of time may adversely affect the patient, and long-acting antihypertensive drugs may gradually exert a hypotensive effect, avoiding the aforementionedBad effects.Some patients started taking the drug for a day or two, and there was no significant decrease in blood pressure. They mistakenly thought that the drug was not effective, and it was wrong to ask for a dressing or dosing.Unless severe hypertension (≥180/110mmHg), there is usually no need for emergency blood pressure reduction, and the blood pressure can be gradually controlled within two or three weeks.Therefore, the initial use of antihypertensive drugs can not be anxious, not to change the drug frequently because the blood pressure has not decreased in two or three days.Clinically, it has also been encountered in some patients after two or three days of medication, blood pressure control is not good, add or increase other drugs, a few weeks after the drug is fully effective, but there is hypotension.Therefore, you need patience when you take the medicine, and you can’t be eager to make it.Frequently Asked Questions and Measures 1 Pain: Headache 1 Reduces the factors that cause or aggravate pain: you need to rest in bed when you have a headache, slow down your posture, avoid fatigue, emotional agitation, nervousness, environmental abhort, etc. Learn to relax techniques, such asIn-the-heart training, music therapy, slow breathing, etc.2 medication safety: when using antihypertensive drugs, measure blood pressure changes to determine the efficacy, to observe whether adverse reactions, such as the use of calcium channel blocker nifedipine headache, facial flushing and lower extremity edema and other adverse reactions.2 There is the possibility of injury 1 Avoid injury: Regularly measure blood pressure, if there is dizziness, vertigo, tinnitus, blurred vision, etc. should stay in bed, need to be accompanied when going to the toilet or going out, avoid changing the position quickly, the activity area is dark, indoors haveObstructions, ground slips, etc.2 prevention and treatment of orthostatic hypotension: the symptoms of orthostatic hypotension are fatigue, dizziness, palpitations, sweating, nausea, vomiting, etc., should be noted when taking drugs, taking the first dose of drugs or adding doses.When you are resting calmly, take a rest after taking the medicine for a period of time and then get out of bed. You should avoid standing for a long time in the first few hours after taking the medicine. Change your posture, especially when you stand up from the lying or sitting position. You should avoid it when you wake up at night.Take a bath or steam bath with overheated water, and it is not suitable for heavy drinking.3 Prevention of complications 1 Avoid incentives: Avoid emotional excitement and keep your mind calm, relaxed and stable.Do not arbitrarily increase or decrease the dose of oral antihypertensive drugs, and do not suddenly stop taking it, so as not to suddenly rise sharply, try to avoid overwork and cold stimulation.Note 1 Calcium channel blockers may cause gingival hyperplasia, but the incidence is very low, generally mild, and will not have a noticeable feeling.In the case of calculus, gingivitis, etc., there may be obvious discomfort, brushing bleeding, or even spontaneous bleeding.If there are no obvious symptoms, no special treatment is required.If the symptoms are obvious or combined with bleeding, consider switching to other types of antihypertensive drugs.Gingival hyperplasia can be relieved after stopping the drug.2 lower extremity edema is a more common side effect of calcium channel blockers, mainly found in the ankle.Most of the time is very light and does not affect treatment.Patients with obvious edema can be combined with low-dose diuretics or sartans or plurs, which can both enhance the antihypertensive effect and help reduce edema.If severe edema occurs, other reasons need to be investigated. It is very rare to use calcium channel blockers to cause severe edema.Lifestyle adhering to a healthy lifestyle and taking antihypertensive drugs are the main methods of treating hypertension, both of which are indispensable.A healthy lifestyle is the foundation, and rational use of drugs is the key to achieving high blood pressure.The two must be combined to effectively control high blood pressure.However, in real life, many patients are over-reliant on drug treatment, ignoring that hypertension is caused in many cases by bad habits.Therefore, maintaining a healthy lifestyle and self-management in life is extremely important for the prevention and treatment of hypertension.Low-salt and low-fat diet first, the Chinese Nutrition Society recommends that daily intake of healthy adults should not exceed 6 g, and patients with hypertension should not exceed 3 g.Second, the daily cooking oil consumption <25 g (half two, equivalent to 2.5 tablespoons); Third, hypertensive patients eat 8 two to 1 kg of fresh vegetables, 1 to 2 fruits per day.For hypertensive patients with diabetes, under the premise of stable blood sugar control, low- or medium-sugar fruits, including apples, kiwis, strawberries, pears, and grapefruits, can be selected.Control body fat rate? Control weight, avoid overweight or even obesity, mainly focus on 3 aspects, that is, whether to achieve ideal body weight, can be assessed by body mass index, normal body mass index is 18.5~23.9; concerned about total fat (body fat), adult maleBody fat does not exceed 25% of body weight; women do not exceed 30% of body weight; attention to the distribution of fat in the body (body type), the more abdominal fat accumulation, the higher the risk of developing diseases such as hypertension.The movements that can be selected for patients with hyperkinesia include aerobic exercise, resistance exercise, flexibility exercise, and balance function.It should be noted that the blood pressure of hypertensive patients is often at a relatively high level in the morning, and the early morning is also a high incidence of cardiovascular events, so it is best to exercise in the afternoon or evening.In addition, there should be 5 to 10 minutes of warm-up exercise and relaxation exercise before and after the formal exercise to avoid sudden and intense exercise and no transition.Hypertensive patients who quit smoking and drink alcohol, the efficacy of antihypertensive drugs is reduced, and it is often necessary to increase the dose.Quitting smoking can significantly reduce the risk of diseases such as cardiovascular disease and cancer.Therefore, the benefits of smoking cessation for patients with hypertension are obvious.Long-term excessive drinking is a risk factor for hypertension and cardiovascular disease. Drinking alcohol can also prevent blood pressure from being controlled by antihypertensive drugs. After drinking alcohol, in addition to blood pressure, the efficacy of antihypertensive drugs is greatly improved..

Sudden mood and long-term anxiety and other psychological abnormalities are one of the important causes of the occurrence and acceleration of primary hypertension. Large psychological fluctuations are also the main predisposing factors of heart and cerebrovascular diseases caused by hypertension.Therefore, prevention and relief of psychological stress are important aspects of hypertension and cardiovascular disease prevention.In daily life, patients should actively learn about the knowledge of hypertension, change their attitudes towards life, relax their mood, and maintain a stable state of mind!


The author ouyangshaoxia