Hypertension

Hypertension – also called “high blood pressure” is one of the most common chronic diseases. It occurs when the blood in the arteries moves under elevated pressure. Hypertension affects more than 20 % of the population. In Bulgaria this percentage is even higher. The real number of the patients exceeds the statistical data, one of the reasons being that many patients overlook the condition and do not seek specialized care.

Bulgarian Hypertension League Data:

• Hypertension affects 42.8% of men and 37.9% of women in active ages (between 24 and 65 years)
• Every 3rd hypertensive person between 35 and 44 years of age does not suspect the disease
• Around half of the patients with hypertension do not use treatment
• The blood pressure control among the medication-taking patients is unsatisfactory – 2 out of 3 men and every 2^nd woman are not able to regulate their blood pressure properly

In clinical practice, arterial hypertension is classified as either primary or secondary.

Primary hypertension, also called essential or idiopathic hypertension, affects around 90% of patients. The underlying factors may vary: stress, overweight, tobacco use, sedentary life style, excessive use of salt, coffee, alcohol, genetic factors.

In secondary hypertension the elevated blood pressure is a symptom of another disease. It is also called symptomatic hypertension and often develops due to kidney diseases (elevation of the diastolic pressure is typical) or an endocrine disorder (Cushing syndrome, Conn syndrome, Pheochromocytoma-adrenal gland tumor, Thyrotoxicosis-hyperfunction of the thyroid gland, hormonal contraceptives intake).

Irrespective of the hypertension cause, the consequences, if left untreated, are severe. There is an increased risk of stroke, myocardial infarction, renal failure and another diseases, due to higher energy loss and heart muscle exhaustion.

The hypertension is diagnosed with measurement of blood pressure. Diagnostic equipment could also be used:  ECG, echocardiography, Doppler echography.

The blood pressure measurement includes two values (systole and diastole), depending on the contraction of the muscle (systole) or the relaxation (diastole) between the beats. The next table shows the normal and elevated values of the blood pressure.

Arterial Hypertension Classification of the International Hypertension Association for 18 y.o. individuals or older.

When hypertension is diagnosed, the first step should be a life-style change (stop smoking, healthy diet, physical activity). In case there is no improvement, pharmacological treatment is recommended.

Antihypertensive drugs:

• Diuretics (Hydrochlorothiazide, Indapamide, Spironolactone, Furozemide). Diuretics are drugs that promote diuresis (increased urine production). They consist of different chemical compounds, stimulating or inhibiting hormones which regulate the urine production. Diuretics are used to treat different types of edema: in chronic heart failure, pulmonary edema due to heart failure, ascites, cerebrum edema, orthostatic edema, edema due to thrombosis or trauma, edema due to treatment with corticosteroid, adrenocorticotropic hormone, phenylbutasone and other drugs. They are also used for blood pressure control. The diuretics decrease the sodium ions in the smooth vascular muscle and the sodium and water extraxtion, leading to decrease of the volume of the blood circulating in the vessels. They are used separately or in combination with other drugs.
• Beta-blockers (Nebivolol, Metoprolol Succinate, Bisoprolol, Carvedilol) ) – are a class of medications that block the beta-adrenoreceptors (adrenalin receptors), displace the adrenalin and terminate its action. There are two groups: cardio selective (block the adrenalin receptors only in the heart muscle cells) and non-selective (block the receptors in other tissues: smooth muscles, air ways, arteries, kidney etc.) Beta blockers decrease the blood pressure and are used as hypertensive drugs. They reduce oxygen consummption of the heart muscle and are used for treatment of stenocardia, ischemic heart disease, cardiac arrhythmias. They reduce the mortality after myocardial infarction and slow down the progression of atherosclerosis. They are used separately or in combination with other drugs.
• ACE-inhibitors (Lisinopril, Ramipril, Quinapril, Enalapril) block the angiotensin-converting enzyme (ACE). This way they eliminate one of the causes for high blood pressure, as the ACE regulate the conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor; it causes vascular constriction and increase of the pressure. Beyond hypertension, ACEis are used in myocardial infarction (reduction the heart damage), diabetes (slow down of the kidney damage), heart failure, cardiovascular prevention. They are used separately or in combination with other drugs.
• Angiotensin II receptor blockers (ARBs) block the activation of AT₁ receptors, preventing the angiotensin II impact on the vessels. They cause vessels dilation, blood pressure decrease and reduce the heart load. They slow down the atherosclerosis progression, improve the endothelium function, regress the hypertrophy of the left ventricle and finally protect the heart and the kidney. There are Olmesartan, Irbesartan, Telmisartan, Valsartan, Losartan, Candesartan. They are used separately or in combination with other drugs.
• Calcium antagonists (Amlodipine, Nifedipine, Verapamil, Diltiazem) – are group of medications that block the calcium channels. They hinder the calcium penetration in the vascular and cardiac cells and so prevent the vessels narrowing. Ca channel antagonists have anti-angina and anti-hypertensive effects and some of them have also anti-arrhythmic action. They are used separately or combined with other drugs.

Combined therapies are used when there is no optimal control of the blood pressure with a single medication. For patient convenience, different medication classes are combined in a single tablet. One of the advantages of combining drugs is the potential to reduce the therapeutic dosages and the possible adverse effects.

• ACЕi  and diuretics (Quinapril/Hydrochlorothiazide, Enalapril/Hydrochlorothiazide, Perindopril/Indapamide)
• ACEi and Ca channel blockers
• ARB and diuretics (Olmesartan/Hydrochlorothiazide, Irbesartan/Hydrochlorothiazide, Telmisartan/Hydrochlorothiazide, Valsartan/Hydrochlorothiazide, Losartan/Hydrochlorothiazide, Candesartan/Hydrochlorothiazide )

Hypercholesterolemia

Hypercholesterolemia – the presence of high levels of cholesterol in the blood is not a disease but may lead to several complications. Long term elevated cholesterol levels in the blood can lead to atherosclerosis development, coronary artery disease (ischemic heart disease), myocardial infarction and increase risk for thromboembolism.

Cholesterol is one of the major cell structure components. It is a part of the membrane’s structure of all cells, participates in the synthesis of biliary acids, steroid hormones and vitamin D. Cholesterol is water insoluble and is transported in the blood plasma connected with specific  protein molecules; together they build  lipoprotein complexes. It can be synthesized in the body or provided by food. There are 2 major types of cholesterol: high density  (HDL – good cholesterol) and low density (LDL – bad cholesterol). They have opposite effects.

Elevated cholesterol may be a consequence of a combined effects of genetic and environment factors. The cholesterol levels increase gradually with the age. The normal range is under 5 mmol/l. High level range between 5-6,4; very high between 6.5-7.8. Levels above 7.8 mmol/l are life-threatening.

Treatment of Hypercholesterolemia

The main choice is a medication of the statin group. These are rosuvastatin, simvastatin and atorvastatin. They reduce the cholesterol synthesis in the liver by blocking the enzymes responsible for its production. This leads to the reduction of the cholesterol levels in the blood, a reduction of the myocardial infarction rate, life prolongation, inflammation reduction, thrombus formation risk reduction, vascular relaxation and dilation. These medications are very stable and have only a few contraindications and side effects. They are recommended in combination with a healthy diet, rich in fibers and non-saturated fats.

Heart failure

Heart failure is a clinical syndrome, caused by the hearts inability to pump enough blood to satisfy the body’s needs. Heart failure symptoms include easy fatigue, loss of breath, reduced physical capacity, pulmonary and/or systemic edema. They are caused by insufficient blood supply to several organs and tissues during physical exertion and fluid retention. This is caused by the heart’s disturbed ability to perform its pumping (systolic) and filling (diastolic) functions.

Heart failure is a serious condition, but if managed well could permit a normal quality of life.

Medications

The main medication groups for heart failure are:

• Diuretics (Hydrochlorothiazide, Indapamide, Spironolactone, Furozemide). Diuretics are drugs that promote diuresis (increased urine production). They consist of different chemical compounds, stimulating or inhibiting hormones which regulate the urine production. Diuretics are used to treat different types of edema: in chronic heart failure, pulmonary edema due to heart failure, ascites, cerebrum edema, orthostatic edema, edema due to thrombosis or trauma, edema due to treatment with corticosteroid, adrenocorticotropic hormone, phenylbutasone and other drugs. They are also used for blood pressure control. The diuretics decrease the sodium ions in the smooth vascular muscle and the sodium and water extraxtion, leading to decrease of the volume of the blood circulating in the vessels. They are used separately or in combination with other drugs.
• Beta-blockers (Nebivolol, Metoprolol Succinate, Bisoprolol, Carvedilol) ) – are a class of medications that block the beta-adrenoreceptors (adrenalin receptors), displace the adrenalin and terminate its action. There are two groups: cardio selective (block the adrenalin receptors only in the heart muscle cells) and non-selective (block the receptors in other tissues: smooth muscles, air ways, arteries, kidney etc.) Beta blockers decrease the blood pressure and are used as hypertensive drugs. They reduce oxygen consummption of the heart muscle and are used for treatment of stenocardia, ischemic heart disease, cardiac arrhythmias. They reduce the mortality after myocardial infarction and slow down the progression of atherosclerosis. They are used separately or in combination with other drugs.
• ACE-inhibitors (Lisinopril, Ramipril, Quinapril, Enalapril) block the angiotensin-converting enzyme (ACE). This way they eliminate one of the causes for high blood pressure, as the ACE regulate the conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor; it causes vascular constriction and increase of the pressure. Beyond hypertension, ACEis are used in myocardial infarction (reduction the heart damage), diabetes (slow down of the kidney damage), heart failure, cardiovascular prevention. They are used separately or in combination with other drugs.
• Angiotensin II receptor blockers (ARBs) block the activation of AT₁ receptors, preventing the angiotensin II impact on the vessels. They cause vessels dilation, blood pressure decrease and reduce the heart load. They slow down the atherosclerosis progression, improve the endothelium function, regress the hypertrophy of the left ventricle and finally protect the heart and the kidney. There are Olmesartan, Irbesartan, Telmisartan, Valsartan, Losartan, Candesartan. They are used separately or in combination with other drugs.
• Nitrates (Isosorbe) – The nitric oxide (NO) is the main metabolic component of the nitrates, that leads to venodilation and reduction of the heart preload. The afterload is also reduced (although to a lesser degree) through periphery vascular resistance reduction (mild to moderate arteries dilation). The effect is oxygen consumption reduction and heart function improvement.

Heart rhythm disorders (Arrhythmias)

Heart arrhythmias are disorders of the normal heart muscle contractions. Depending the type of change (acceleration or deceleration), they are tachyarrhytmias or bradyarrhytmias. In general they are divided into a trial and ventricles arrhythmias, as well as conduction disorders, affecting the nerve impulse transmission.

Heart arrhythmias medications resolve symptoms and prolong life expectancy.

Anti-arrhytmic drugs (Flecainide) are the first choice for arrhythmias management.

Ischemic heart disease

The heart a vital body organ, it’s a “muscle pump” that enables blood supply to all organs and tissues. It has his own coronary artery system, which delivers the necessary nutrients and oxygen to the heart’s muscles.

Ischemic heart disease develops when one or more coronary arteries become narrowed or occluded and the heart muscle doesn’t have enough oxygen supply , leading to dysfunction. Ischemic heart disease is one of the most common cardiovascular diseases and has several types:

• Stable angina pectoris
• Unstable angina pectoris
• Myocardial infarction
• Myocardial sclerosis

Treatment:

• Nitroglycerin – relieves chest pain.
• Beta-blockers (Nebivolol, Metoprolol , Bisoprolol, Carvedilol) – are a class of medications that block the beta-adrenoreceptors (adrenalin receptors), displace adrenalin and terminate its action. There are two groups: cardio selective (block the adrenalin receptors only in the heart muscle cells) and non-selective (block the receptors in other tissues: smooth muscles, air ways, arteries, kidney etc.). Beta blockers decrease the blood pressure and are used as a hypertensive drug. They reduce oxygen consumption of the heart muscle and are used for treatment of stenocardia, ischemic heart disease and cardiac arrhythmias. They reduce the mortality after myocardial infarction and slow down the progression of atherosclerosis. They are used separately or in combination with other drugs.
• ACE-inhibitors (Lisinopril, Ramipril, Quinapril, Enalapril) block the angiotensin-converting enzyme (ACE). This way they eliminate one of the causes for high blood pressure, as the ACE regulate the convert of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor; it causes vascular constriction and increase of the pressure. Beyond hypertension ACEi are used in myocardial infarction (reduce the heart damage), diabetes (slow down the kidney damage), heart failure, cardiovascular prevention. They are used separately or in combination with other drugs.
• Antithrombotic drugs (Clopidogrel, Acetylsalicylic acid) are medications that reduce the clot formation risk and prolong life.
• Statins (rosuvastatin, simvastatin and atorvastatin). They reduce the cholesterol synthesis in the liver by blocking the enzyme responsible for its production. The cholesterol level in the blood is reduced, which leads to reduction of the myocardial infarction rate, life prolongation, inflammation reduction, thrombus formation risk reduction of, vascular relaxation and dilation. These medications are very stable and have only a few contraindications and side effects. It is recommended to be combined with a healthy diet rich in fibers and non-saturated fats.
• Calcium antagonists (Amlodipine,  Nifedipine,  Verapamil,  Diltiazem) – are a group of medications that block the calcium channels. They hinder the calcium penetration in the vascular and cardiac cells and so prevent the vessels narrowing. Ca channel antagonists have anti angina and anti hypertensive effects and some of them have also anti arrhythmic action. They are used separately or in combination with other drugs.