Diagnosis of arterial hypertension

When collecting an anamnesis, it is necessary to obtain information from the history of life and disease, as well as the hereditary burden on cardiovascular diseases in the family, and it is necessary to specify the age of the manifestation of cardiovascular disease in relatives. Analyze the course of pregnancy and childbirth to identify possible perinatal pathology.

It is necessary to learn about the presence of conflict situations in the family and school, violations of sleep and rest (lack of sleep), to obtain information about the nature of eating habits, paying particular attention to irregular, unbalanced diet, excessive intake of salt (a tendency to dosing out cooked food). Specify the presence of bad habits: alcohol use, smoking, the use of certain medications (amphetamine, pressor drugs, steroids, tricyclic antidepressants, oral contraceptives), narcotic drugs and other stimulants, including plant origin (food additives). It is necessary to evaluate physical activity: physical inactivity or, conversely, an increased level of physical activity (occupations in sports sections that can lead to a syndrome of sports overexertion).

Clarify complaints of the child (headache, vomiting, sleep disturbances), blood pressure level and duration of arterial hypertension, clarify the previously conducted antihypertensive therapy.

Carry out a thorough examination of the patient. Pay attention to the condition of the skin. Changes in the skin can be manifestations of one of the diseases that cause symptomatic arterial hypertension. Stains of color "coffee with milk are often observed with pheochromocytoma. The mesh is a typical symptom of nodular periarteritis. The presence of striae is characteristic of hypercortisolism. Neurofibromatous nodes indicate the possibility of Recklinghausen's disease. The increased skin moisture is characteristic for thyrotoxicosis or vegetotvascular dystonia syndrome.

On examination, the swelling of the vascular veins is assessed as a criterion of venous hypertension. Auscultation of noise above the carotid artery should be regarded as a possible symptom of aortoarteritis, an increase in the thyroid gland may indicate hypo- or hyperthyroidism.

Auscultation includes both the heart area and the abdominal cavity in order to identify stenosis of renal vessels. It is necessary to determine pulsation in peripheral arteries to detect asymmetry and / or reduce pulsation, which allows one to suspect coarctation of the aorta or aortoarteriitis. When examining the abdomen exclude voluminous formations (Wilms tumor, abdominal aortic aneurysm, polycystic kidney disease). Auscultation of noise over the aorta or renal arteries may reflect coarctation of the aorta, stenosis of the renal arteries.

Evaluation of sexual development is carried out on the Tanner scale.

ECG is an obligatory method of diagnosis. The signs of atrial overload and the state of the final part of the ventricular complex are evaluated to detect an increased sensitivity of beta-adrenoreceptors to catecholamines. Decrease in the ST segment and flattening of the T wave is an indication for carrying out a drug sample with obzidan from the calculation of 0.5 mg / kg.

Echocardiography - an obligatory method of diagnosis - allows you to identify:

• signs of hypertrophy of the left ventricle (thickness of the interventricular septum and posterior wall of the left ventricle over the 95th percentile of the distribution of this index);
• an increase in the mass of the myocardium of the left ventricle (more than 110 g / m ² );
• diastolic left ventricular function, decreased left ventricular relaxation (decrease in the early peak of diastolic filling E / A <1.0 according to the data of the transmittal Doppler flow), which serves as a criterion for stable forms of arterial hypertension and reflects the presence of diastolic dysfunction in the hypertrophic type.

Cardiac hemodynamics is assessed by cardiac and percussive ejection, the OPSS is calculated indirectly by the Frank-Poiseuille formula:

OPSS = АД _ср х 1333 х 60 + МО,

Where AD is the mean hemodynamic blood pressure (BP = 1/3 pulse BP + DBP); MO - minute volume of circulation (MO = stroke volume x HR).

Depending on the parameters of the minute volume and the OPSS, three types of hemodynamics are distinguished: eukinetic, hyperkinetic and hypokinetic.

Characteristics of hemodynamic types in healthy children

Type of hemodynamics	Indices of central hemodynamics
	Cardiac index, l / m 2	Total peripheral vascular resistance, dyne / cm / sec *
		Normal	Increased	Lowered
Eukinetic	3.1-4.6	1057-1357	> 1375	<1057
Hyperkinetic	> 4.6	702-946	> 946	<702
Hypokinetic	<3.1	1549-1875	> 1B75	<1549

X-ray examination is practically non-informative, except for cases of coarctation of the aorta, when a specific feature is identified - the ribbing.

Examination of the fundus allows to detect narrowing and tortuosity of small arteries, possibly, dilatation of the veins of the fundus.

Assessment of the state of the autonomic nervous system should be done using clinical tables to assess the initial vegetative tone, vegetative reactivity (according to cardiointervalography) and vegetative activity support (according to the results of a clinoortostatic test).

Echoencephalography is performed with frequent complaints of headaches, clinical signs of hypertensive syndrome to exclude intracranial hypertension.

Rheoencephalography makes it possible to reveal a violation of vascular tone in the cerebral vessels, a difficult venous outflow. Children with hyper- and hypokinetic types of hemodynamics often notice a decrease in vascular blood filling. The data obtained serve as an indication for the administration of drugs to improve microcirculation.

Ultrasound examination of the kidney in combination with urinalysis - screening to exclude renal genesis of arterial hypertension, if necessary, perform excretory urography.

Biochemical examination includes the following analyzes:

• determination of the lipid spectrum of blood (total cholesterol, triglycerides, high-density lipoprotein cholesterol);
• conducting a glucose tolerance test (for obesity);
• determination of the level of catecholamines (epinephrine, norepinephrine, in case of suspected pheochromocytoma - vanillylmandelic acid);
• evaluation of the activity of the renin-angiotensin-aldosterone system (determination of the level of renin, angiotensin and aldosterone).

Method of daily monitoring of arterial pressure

Daily monitoring of arterial pressure allows us to verify the initial deviations in the daily rhythm and blood pressure value, to carry out differential diagnosis of various forms of arterial hypertension.

At daily monitoring of arterial pressure the following parameters are calculated: average values of arterial pressure (systolic, diastolic, average hemodynamic pulse) for day, day and night; indices of time of arterial hypertension in different periods of the day (day and night); variability of blood pressure in the form of standard deviation, coefficient of variation and daily index.

Mean values of arterial pressure (systolic, diastolic, mean hemodynamic, pulse) give a basic idea of the level of arterial pressure in the patient, more accurately reflect the true level of arterial hypertension than single measurements.

The time index of hypertension allows you to estimate the time of increase in blood pressure during the day. This indicator is calculated from the percentage of measurements exceeding the normal blood pressure values for 24 hours or separately for each time of day. The time index exceeding 25% for SBP is unequivocally treated as pathological. With a labile form of hypertension, the time index ranges from 25 to 50%, with a stable form exceeding 50%.

The daily index gives an idea of the circadian organization of the daily profile of blood pressure. It is calculated as the difference between the mean daily and night values of blood pressure in percent of the daily average. For most healthy children, a nightly decrease in blood pressure is 10-20% compared to daytime rates. There are four options, depending on the value of the daily index.

The values of the 50th and 95th percentile of arterial pressure from daily monitoring in children and adolescents as a function of growth (Soergel et al., 1997)

Height, cm	Blood pressure during the day, mm Hg.		BP during the day, mmHg.		Blood pressure during the night, mmHg.
	50th percentile	95th percentile	50th Lercentile	95th percentile	50th percentile	95th percentile

Boys

120	105/65	113/72	112/73	123/85	95/55	104/63
130	105/65	117/75	113/73	125/85	96/55	107/65
140	107/65	121/77	114/73	127/85	97/55	110/67
150	109/66	124/78	115/73	129/85	99/56	113/67
160	112/66	126/78	118/73	132/85	102/56	116/67
170	115/67	128/77	121/73	135/85	104/56	119/67
180	120/67	130/77	124/73	137/85	107/55	122/67

Girls

120	103/65	113/73	111/72	120/84	96/55	107/66
130	105/66	117/75	112/72	124/84	97/55	109/66
140	108/66	120/76	114/72	127/84	98/55	111/66
150	110/66	122/76	115/73	129/84	99/55	112/66
160	111/66	124/76	116/73	131/84	100/55	113/66
170	112/66	124/76	118/74	131/84	101/55	113/66
180	113/66	124/76	120/74	131/84	103/55	114/66

• Normal decrease in blood pressure at night: the daily index of blood pressure varies from 10 to 20% (in the English-language literature, such persons are referred to as "dippers" ).
• Absence of a decrease in blood pressure at night: the daily index is less than 10% (such persons are classified as "n-dippers" ).
• Excessive decrease in arterial pressure at night: daily index more than 20% ( "over-dippers" ).
• Blood pressure elevation at night: the daily index is less than 0% (" night-peakers" ).

Normally, children do not observe the values of night blood pressure, exceeding the average daily values ("night-peakers"). Such daily profile of arterial pressure is characteristic for persons with symptomatic arterial hypertension.

In healthy children, the mean values of mean hemodynamic blood pressure are observed at 2 hours, later the arterial pressure rises and reaches the first peak by 10-11 am, moderately reduced to 16 hours, and the second peak is observed at 19-20 hours.

The method of daily monitoring of arterial pressure is necessary for differential diagnostics of various forms of arterial hypertension.

Data of daily monitoring of arterial blood pressure in children allow to avoid hyperdiagnosis of arterial hypertension due to revealing the increase in arterial pressure due to excessive anxiety reaction associated with medical examination - the phenomenon of "hypertension of a white coat". The frequency of the phenomenon of "white coat hypertension" among children with arterial hypertension, according to our data, is 32%, while in the daily profile of arterial pressure there are short-term elevations of blood pressure above normal, while mean values of blood pressure remain within acceptable limits.

The criteria for diagnosing labile forms of arterial hypertension from the data of daily monitoring of arterial pressure are as follows:

• increase in mean values of systolic and / or diastolic arterial pressure from 90th to 95th percentile of distributions of these parameters for the corresponding growth indices;
• the excess of the normative values of the hypertension time index in the daytime and / or night time by 25-50%;
• increased variability of blood pressure.

The criteria for the diagnosis of stable forms of arterial hypertension according to the data of daily monitoring of arterial pressure are listed below:

• an increase in the mean values of systolic and / or diastolic arterial pressure above the 95th percentile of the distributions of these parameters for the corresponding growth indices;
• the excess of the normative values of the time index of hypertension in the daytime and / or night time by more than 50%.

Daily monitoring of arterial pressure allows us to develop differential diagnostic criteria for the appointment of non-drug vegetative or antihypertensive therapy. Non-pharmacological methods for correcting high blood pressure are indicated for occasional increases (with "white coat hypertension"). Children with the phenomenon of "hypertension white coat" are subject to long-term follow-up as part of the risk group for the development of hypertension. Daily monitoring of blood pressure makes it possible to evaluate the effectiveness of antihypertensive therapy, to establish the correct intervals between doses of the drug during the day, to avoid unreasonably high doses of antihypertensive drugs.

A sample with dosed physical activity provides important information for the diagnosis of hypertension in children and adolescents. It allows you to determine tolerance to physical activity, to identify the disadaptive hemodynamic changes that occur when performing physical exertion (hypertensive type of hemodynamics). For adolescents with arterial hypertension are characterized by lower indicators of the capacity of the load and the amount of work performed. To a greater extent, a decrease in physical performance is characteristic of adolescents with stable arterial hypertension.

Children with arterial hypertension have higher levels of DBP and SBP when compared with children with normal blood pressure values during a physical exercise test. The frequency of hypertensive reaction of arterial pressure to physical activity (blood pressure level more than 170/95 mm Hg) is 42% with a labile form of arterial hypertension, with a stable form of 80%.

Diagnosis of target organ damage

Timely diagnosis of damage to target organs, primarily, the detection of cardiac remodeling and changes in the vascular wall, is extremely important for determining the stage of the disease and evaluating the prognosis of children with high blood pressure. Increased blood pressure contributes to atherosclerotic vascular damage. This position was confirmed by the data of a morphological study of the state of the cardiovascular system in adolescents and young adults who died as a result of accidents. A close relationship was established between the increased level of arterial pressure and the severity of the atherosclerotic process in the aorta and coronary arteries, as well as the occurrence of myocardial hypertrophy. These patterns were also confirmed by the results of non-invasive methods for the diagnosis of vascular lesions, such as echodopplerography, in young adults with arterial hypertension. It was found that the increase in arterial pressure in childhood is associated with an increase in the thickness of the middle and inner dimensions of the carotid arteries of intima media at the age of 20-30 years.

Hypertrophy of the left ventricle is the most striking feature of target organ damage in hypertension. At present, the most informative noninvasive method for diagnosing myocardial hypertrophy is Doppler echocardiography. The main criterion for diagnosing myocardial hypertrophy of the left ventricle is the mass of the myocardium. According to the recommendations of the IV report on diagnosis and treatment of hypertension of the National Education Program for estimating the mass of the left ventricular myocardium, the following formula should be used:

MMLZH = 0,8х (1,04hTMR + KDR + TZSLŽ) ³ - КДР ³ +0,6,

Where LVMI is the mass of the myocardium of the left ventricle (g), TMVL is the thickness of the IVF (cm), the CDR is the final diastolic dimension of the left ventricle (cm), TZSLZH is the thickness of the posterior left ventricle (cm).

Given that the mass of the myocardium is closely associated with weight and height, a more informative criterion for left ventricular hypertrophy is the left ventricular mass index, leveling the effect of overweight on this indicator. The left ventricular mass index is calculated as the ratio of the LVDM to the growth (m) value, raised to a power of 2.7. Then the value of this indicator is compared with the percentile tables. A single, so-called strict criterion, indicating the presence of hypertrophy, is the index of the LVML, equal to or exceeding the value of 51 g / m ^2.7. This value corresponds to the 99th percentile of the indicator in children and adolescents. This value of the LVDM index is closely associated with a high risk of adverse outcomes of hypertension in adult patients. Hypertrophy of the myocardium is revealed in 34-38% of children and adolescents with arterial hypertension. About 55% of adolescents with arterial hypertension have an LVDM index above the 90th percentile, and 14% exceed 51 g / m ^2.7.

Arterial hypertension is associated with the process of myocardial remodeling. Thus, concentric hypertrophy of the myocardium, which serves as a predictor of a high risk of developing cardiovascular complications in adults, was noted in 17% of children, in 30% there was eccentric hypertrophy, associated with a lower risk of complications in adulthood. The detection of left ventricular hypertrophy is extremely important, since it serves as an absolute indication for the appointment of antihypertensive therapy. It should be emphasized that the definition of the LVDM index should be carried out in dynamics to assess the effectiveness of the therapy. The detection of left ventricular hypertrophy is a more unfavorable prognostic factor for assessing the severity of the course of arterial hypertension compared with changes in carotid artery thickness (intima / media index) and the detection of microalbuminemia.

Several studies have shown the relationship between hypertension and retinopathy.

Diagnosis of psychological characteristics of adolescents with arterial hypertension

The sensitivity of the cardiovascular system of adolescents to emotional influences is determined by constitutional-typological and personal characteristics. In this regard, in the survey of adolescents with arterial hypertension, it is advisable to include psychological testing using tests of Eysenck, Spielberger, Wolff. The choice of these tests is due to high informativeness combined with ease of implementation. Their conduct does not require the participation of a psychologist available to a pediatrician, a cardiologist.

Test Eysenck allows you to identify the characteristics of adolescents. Under extroversion is understood such personality traits as sociality, contactness, activity, cheerfulness, optimism, aggressiveness, individuality. Extroversion is typical for the adolescent period. Under the introversion is understood such personality traits as restraint, a tendency to introspection and inner experiences, strict control over emotions and feelings. For adolescents with arterial hypertension, intraverting is more typical.

Intraversion is combined with increased sympathicotonic activity. On the emotional lability are high indices on the scale of "neuroticism".

The relationship between hypertension and anxiety is well known. In the opinion of Academician B.D. Carvaskar, anxiety is a mental state, the determinative factor in which is the condition of uncertainty. The Spielberger test reveals the level of both personal and reactive anxiety. Personal anxiety is a character characteristic of an individual, reactive anxiety is a reaction to a stressful situation. For adolescents with arterial hypertension, elevated levels of both reactive and personal anxiety in the Spielberger test are characteristic.

Wolf's test reveals the behavioral characteristics characteristic of types A and B behavior. Classical psychological characteristics of behavior of type A - the thirst for competition, a sense of lack of time, aggressiveness, hostility, purposefulness, the desire for leadership, a high degree of control over behavior in situations that threaten outcomes undesirable for the subject. Children with behavior type A are irritable under stress and aggressive during the game. Type A is more common in boys than in girls. In addition, for boys more characteristic components of type A behavior, such as aggression and the thirst for competition, which is associated with a large release of catecholamines. These factors may contribute to a greater predisposition of men compared to women for cardiovascular disease. Type A behavior is characterized by more frequent damage to the vascular endothelium.

Thus, psychological testing can reveal disadaptive behavioral characteristics, such as increased anxiety, a tendency to aggressive reactions, requiring psychological correction.

[1], [2], [3], [4], [5], [6], [7], [8], [9]