What is hypertension encephalopathy

Arterial hypertension

Abstract

Arterial hypertension is a common disease and is the most widespread cardiovascular risk factor (affects over half of all> 50-year-olds in Germany). The frequent presence of other risk factors such as obesity, diabetes mellitus or nicotine consumption further increases the risk of cardiovascular disease or stroke. The fact that the disease often remains symptom-free is aggravating for the patient's identification and understanding of the disease. A hypertonic blood pressure situation is reached from a resting blood pressure of 140/90 mmHg - the start of treatment and target blood pressure depend on the overall risk constellation.

The first measure should always be a change in lifestyle - albeit often difficult to implement - with weight loss, sufficient exercise and abstinence from alcohol and nicotine. Depending on the risk profile, drug therapy is also indicated for most people. For this purpose, a dual therapy consisting of an ACE inhibitor / sartan and a diuretic / calcium antagonist should be used as standard. The patient's existing comorbidities should be taken into account in the final selection of the preparations.

An acute complication can be a hypertensive crisis with systolic blood pressure values> 180–230 mmHg, which requires careful but consistent treatment, as otherwise serious consequences (such as cerebral hemorrhage) can occur. Long-term consequences of arterial hypertension are multiple end organ damage - including to the eye (hypertensive retinopathy), heart (hypertensive cardiomyopathy, CHD, myocardial infarction), brain (stroke) or kidney (hypertensive nephropathy).

definition

Limit values ​​according to the ESC guideline 2018

As part of a 24-hour blood pressure measurement, arterial hypertension is diagnosed in the overall evaluation from average values ​​of ≥130 / 80 mmHg!

Investigations into the optimal blood pressure value are the subject of current research. A critical view is appropriate, since different (partly economically oriented) interest groups exert influence!

Epidemiology

Unless otherwise stated, the epidemiological data refer to Germany.

etiology

Essential (primary) hypertension

Secondary hypertension

Symptoms / clinic

  • The arterial hypertension is often symptom-free (especially the longer one)
  • Clinical symptoms often only exist in special situations such as: Hypertensive emergency (see: "Course and special forms")
  • Possible complaints
    • Dizziness, ringing in the ears
    • a headache
      • The back of the headache in the early morning hours is particularly typical
    • Palpitations, thoracic discomfort
    • Epistaxis
    • Sleep disorders (in case of hypertension at night)
    • Symptoms of complications

Ascribing a patient's complaints to high blood pressure runs the risk of overlooking the real cause. Hypertension can be both a cause and a consequence of certain symptoms (e.g. headaches)!

Gradient and special forms

Renal artery stenosis

Only a renal artery stenosis of more than 60% promotes renovascular hypertension (Goldblatt mechanism) via activation of the RAAS!

Angioplasty of an uncomplicated renal artery stenosis with easily adjustable blood pressure should not be performed. (DGIM - Smart Decisions in Nephrology)

Malignant hypertension

  • definition
  • Etiology: It can develop in any form of hypertension
  • Complications: malignant nephrosclerosis, hypertensive encephalopathy
  • Therapy: Reduction of the blood pressure to below 110 mmHg diastolic within 24 hours
  • Prognosis: Without treatment, fatal in up to 50% within one year

Diagnosis

General diagnostics

  • aim
  • Medical history and clinical examination
    • Including pulse quality: if necessary, pulsus durus (hard, hard-to-print pulse)
  • Laboratory diagnostics: urinary status (including test for microalbuminuria), creatinine i.S., serum electrolytes, blood sugar, cholesterol, triglycerides, etc.
  • Blood pressure measurement
    • Practice blood pressure measurement: Repeated blood pressure measurement on both arms at different times[2]
      • CAVE! White coat hypertension: arterial hypertension only during a clinical visit or measurement in the doctor's office
      • Before the measurement: Allow the patient to sit for 3–5 minutes
      • Applying the blood pressure cuff at heart level
      • For the first measurement: measurement on both arms[3]
      • Perform two measurements while sitting, 1–2 min apart
      • Pay attention to possible sources of error when measuring blood pressure
  • RR self-measurement after training: Best method for therapy monitoring and for increasing compliance
  • 24-hour blood pressure measurement ("long-term RR"): Repeated blood pressure measurement using a portable device over a longer period of time (usually 24 hours), usually on an outpatient basis

Possible sources of error when measuring blood pressure

  • Mönckeberg media sclerosis
  • Measurement above / below the heart level
  • Maximum extension of the arm (it should be measured with a slight flexion)
  • Difference in circumference of the arms
  • Use of blood pressure cuffs that are too narrow or too wide: If the blood pressure cuff is too narrow, the values ​​measured are too high; if the blood pressure cuff is too wide, the values ​​are too low! Rule of thumb: The cuff width should be about half the circumference of the upper arm.
  • "Auscultatory gap"

The initiation of therapy without a subsequent search for further cardiovascular risks is a malpractice!

Follow-up examinations in high-risk patients should include creatinine determinations and urine status. (DGIM - Smart Decisions in Nephrology)

Indications for the presence of secondary hypertension

  • Generally
    • About 10% of all cases
    • Young age (
    • Sudden worsening of blood pressure despite reliable medication intake
    • Non-dipper in long-term RR (lack of physiological drop in blood pressure at night)
      • Is in the case of waste
    • Recurrent hypertensive crises
    • Therapy refractory despite triple combination
  • Special