🫀 Interná medicína · 4

Artériová hypertenzia (etiológia, patogenéza, klasifikácia, diagnostika, liečba, komplikácie)

Definícia

• Artériová hypertenzia je časté chronické ochorenie charakterizované trvalým zvýšením artériového tlaku. ESC 2024 klasifikuje ordinačný TK ako nezvýšený (< 120/70 mmHg), zvýšený (120–139/70–89 mmHg) a hypertenziu (≥ 140/90 mmHg).

Etiológia a patogenéza

• Väčšina prípadov je idiopatická – esenciálna (primárna) hypertenzia.
• Patogenéza esenciálnej hypertenzie: napr. zvýšená absorpcia soli s expanziou objemu, porucha odpovede systému renín-angiotenzín-aldosterón a zvýšená aktivita sympatiku, ktoré vedú k zvýšeniu celkovej periférnej rezistencie.
• Sekundárna hypertenzia: príčinou je napr. renálna parenchýmová choroba (najmä diabetická nefropatia, chronická glomerulonefritída, polycystóza obličiek) alebo primárny hyperaldosteronizmus, ktorý je najčastejšou endokrinnou príčinou.
• Ďalšie sekundárne príčiny, napr.: renovaskulárna hypertenzia (u starších aterosklerotická stenóza renálnej artérie, u mladších – najmä žien – fibromuskulárna dysplázia), obštrukčné spánkové apnoe, koarktácia aorty (typicky u mladých dospelých).

Klinický obraz

• Väčšina prípadov je asymptomatická a diagnostikuje sa náhodne pri meraní TK; mnohí pacienti o ochorení nevedia („tichý zabijak“).
• Niekedy sa prejaví priamo poškodením cieľových orgánov – napr. príznakmi CMP, hypertenznou encefalopatiou, bolesťou na hrudi, dušnosťou alebo akútnym edémom pľúc.
• Primárny hyperaldosteronizmus: hypokaliémia je prítomná len u menšiny pacientov – jej absencia diagnózu nevylučuje.
• Koarktácia aorty: hypertenzia na horných a hypotenzia na dolných končatinách, oslabené alebo oneskorené femorálne pulzy, radiofemorálne oneskorenie pulzu a systolický šelest na chrbte.

Diagnostika

• ESC 2024: na potvrdenie diagnózy aj pri ďalšom sledovaní sa odporúča meranie TK mimo ambulancie (trieda I); opakované ordinačné meranie len vtedy, ak meranie mimo ambulancie nie je uskutočniteľné.
• Na posúdenie poškodenia cieľových orgánov sa u všetkých hypertonikov odporúčajú napr. sérový kreatinín, eGFR, pomer albumín/kreatinín v moči a 12-zvodové EKG; echokardiografia pri abnormálnom EKG alebo pri príznakoch srdcového ochorenia (ESC 2024).
• ESC 2024: skríning primárneho hyperaldosteronizmu (renín a aldosterón) zvážiť u všetkých dospelých s potvrdenou hypertenziou (trieda IIa); u mladých dospelých (< 40 rokov) komplexný skríning hlavných sekundárnych príčin (trieda I), u obéznych mladých dospelých začať vyšetrením na obštrukčné spánkové apnoe.
• Pri zvýšenom TK sa u osôb bez vysokorizikových stavov odhaduje 10-ročné KV riziko pomocou SCORE2 alebo SCORE2-OP.

Liečba

• ESC 2024: pri potvrdenej hypertenzii (≥ 140/90 mmHg) ihneď režimové opatrenia aj farmakoterapia bez ohľadu na vek a KV riziko (trieda I); pri TK 130–139/80–89 mmHg farmakoterapia až po 3 mesiacoch režimových opatrení a len pri vysokom KV riziku (napr. KVO, diabetes, stredne ťažká alebo ťažká CKD, poškodenie cieľových orgánov, 10-ročné riziko ≥ 10 %).
• Lieky 1. línie: ACE inhibítory, ARB, dihydropyridínové blokátory Ca kanála a tiazidové alebo tiazidom podobné diuretiká; betablokátory v kombinácii pri presvedčivej indikácii (napr. HFrEF). U väčšiny pacientov úvodne dvojkombinácia vo fixnej kombinácii, pri nedostatočnom efekte trojkombinácia.
• Cieľový systolický TK je u väčšiny dospelých 120–129 mmHg, ak je liečba tolerovaná; uvoľnené ciele (TK tak nízky, ako je rozumne dosiahnuteľné) pri intolerancii liečby, veku ≥ 85 rokov, symptomatickej ortostáze, stredne ťažkej až ťažkej krehkosti alebo obmedzenom očakávanom prežití.
• ACE inhibítory a ARB sú absolútne kontraindikované napr. v gravidite a pri bilaterálnej stenóze renálnych artérií (alebo stenóze pri solitárnej funkčnej obličke); duálna blokáda RAAS (ACEi + ARB alebo s aliskirénom) je kontraindikovaná.

Komplikácie a prognóza

• Hypertenzia významne prispieva k vzniku napr. CMP, infarktu myokardu, srdcového zlyhávania a zlyhania obličiek.
• CMP môže byť ischemická aj vo forme intracerebrálneho krvácania; ďalej hypertenzná encefalopatia.
• Ďalšie komplikácie nekontrolovanej hypertenzie sú napr. ischemická choroba srdca, periférne artériové ochorenie, fibrilácia predsiení a aneuryzma aorty.

Kľúčové pojmy

artériová hypertenzia	hypertensio arterialis
esenciálna hypertenzia	hypertensio essentialis
sekundárna hypertenzia	hypertensio secundaria
primárny hyperaldosteronizmus	hyperaldosteronismus primarius
feochromocytóm	phaeochromocytoma
koarktácia aorty	coarctatio aortae
fibromuskulárna dysplázia
ambulantné monitorovanie TK (ABPM)
hypertrofia ľavej komory	hypertrophia ventriculi sinistri
rezistentná hypertenzia

📎 Zdroje:

Essential Hypertension - StatPearls - NCBI Bookshelf (definícia)Hypertension ranks among the most common chronic medical condition characterized by a persistent elevation in arterial pressure.
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (definícia)i) non-elevated (office BP <120/70 mm Hg) for which drug treatment is not recommended, ii) elevated (120–139/70–89 mm Hg) for which drug treatment is recommended based on cardiovascular disease risk and follow-up BP level, and iii) hypertension (≥ 140/90 mm Hg)
Essential Hypertension - StatPearls - NCBI Bookshelf (etiology[0])Most cases of hypertension are idiopathic, which is also known as essential hypertension.
Essential Hypertension - StatPearls - NCBI Bookshelf (etiology[1])There are various mechanisms described for the development of hypertension, which include increased salt absorption resulting in volume expansion, an impaired response of the renin-angiotensin-aldosterone system (RAAS), and increased activation of the sympathetic nervous system.
Essential Hypertension - StatPearls - NCBI Bookshelf (etiology[1])These changes lead to the development of increased total peripheral resistance and increased afterload, which in turn leads to the development of hypertension.
Secondary Hypertension - StatPearls - NCBI Bookshelf (etiology[2])The most common renal parenchymal diseases leading to secondary hypertension include diabetic nephropathy, chronic glomerulonephritis, glomerulosclerosis, and autosomal dominant polycystic kidney disease
Secondary Hypertension - StatPearls - NCBI Bookshelf (etiology[2])Notably, primary aldosteronism is found in 5% to 10% of patients with hypertension, making it the most common endocrine cause.
Secondary Hypertension - StatPearls - NCBI Bookshelf (etiology[3])Atherosclerotic renal artery stenosis predominates in older adults and is often associated with generalized atherosclerotic disease, while fibromuscular dysplasia is the typical cause in younger patients, particularly women.
Secondary Hypertension - StatPearls - NCBI Bookshelf (etiology[3])Obstructive sleep apnea is increasingly recognized as one of the most common identifiable causes of secondary and resistant hypertension.
Secondary Hypertension - StatPearls - NCBI Bookshelf (etiology[3])Coarctation of the aorta is the prototypical vascular cause of secondary hypertension in young adults
Essential Hypertension - StatPearls - NCBI Bookshelf (clinical[0])Most cases of hypertension are asymptomatic and are diagnosed incidentally on blood pressure recording or measurement.
Essential Hypertension - StatPearls - NCBI Bookshelf (clinical[0])most of these hypertensive patients might be unaware of their disease, hence the name "silent killer."
Essential Hypertension - StatPearls - NCBI Bookshelf (clinical[1])Some cases present directly with symptoms of end-organ damage as stroke-like symptoms or hypertensive encephalopathy, chest pain, shortness of breath, and acute pulmonary edema.
Secondary Hypertension - StatPearls - NCBI Bookshelf (clinical[2])Hypokalemia is present in only a minority of patients with primary aldosteronism; its absence does not exclude the diagnosis.
Secondary Hypertension - StatPearls - NCBI Bookshelf (clinical[3])Coarctation of the aorta: Upper extremity hypertension with lower extremity hypotension, diminished or delayed femoral pulses, radiofemoral pulse delay, and a systolic murmur over the back are signs of coarctation of the aorta.
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (diagnostics[0])The 2024 ESC guideline places increased emphasis on and a Class I recommendation for out-of-office BP measurement in both the diagnosis and subsequent management of elevated BP and hypertension
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (diagnostics[0])with repeat office measurement usage only recommended if out-of-office measurement is not logistically/economically feasible.
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (diagnostics[1])The 2024 ESC guideline specifically recommends measurement of serum creatinine, eGFR, and urine albumin/creatinine ratio (Class I) in all patients with hypertension
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (diagnostics[1])a 12-lead ECG in all patients with hypertension (Class I), an echocardiogram in patients with hypertension and ECG abnormalities or signs/symptoms of cardiac disease (Class I)
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (diagnostics[2])the ESC guideline also advises that screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension (Class IIa).
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (diagnostics[2])For young adults (< 40 years of age), comprehensive screening for the main causes of secondary hypertension is recommended by the 2024 ESC guideline (Class I), except for obese young adults where it is recommended to simply start with an obstructive sleep apnoea evaluation.
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (diagnostics[3])Second, in the absence of these high-risk conditions, the guideline recommends using the Systematic COronary Risk Evaluation 2 (SCORE2) or Systematic COronary Risk Evaluation 2 Older Persons (SCORE2-OP) to predict 10-year risk CVD events.
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[0])The 2024 ESC guideline recommends prompt initiation of both lifestyle and BP-lowering pharmacological therapy for individuals with confirmed hypertension (≥140/90 mmHg) irrespective of age and CVD risk (Class I).
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[0])initiation of pharmacological therapy for those with SBP 130–139 or DBP 80–89 mmHg after 3 months of lifestyle therapy in a broader population with high-risk CVD conditions (established CVD, HMOD, diabetes mellitus, moderate or severe CKD, and familial hypercholesterolemia)
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[0])individuals with a 10-year predicted CVD risk of 10% or greater
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[1])The 2024 ESC guideline recommends angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), dihydropyridine calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics as the first line BP-lowering agents (Class I).
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[1])the 2024 ESC guideline recommends (Class I) beta blockers are combined with one of these other major classes when there is a compelling indication (e.g. heart failure with reduced ejection fraction).
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[1])The 2024 ESC and 2023 ESH guidelines recommend initial two-drug fixed dose combination therapy in most patients with hypertension (Class I in both guidelines) with similar exceptions.
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[1])Both guidelines recommend a three-drug combination if a two-drug combination is not sufficient to control BP
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[2])The initial default systolic BP treatment target is 120–129 mmHg for most; however, relaxed targets (BP as low as reasonably achievable) are recommended in case of treatment intolerance, adults ≥85 years, symptomatic orthostasis, moderate-to-severe frailty, or limited life expectancy.
What's New and Different in the 2024 ESC Guideline for the Management of Elevated BP and Hypertension? (Hypertension 2025, PMC) (treatment[2])The 2024 ESC guideline recommends an initial default SBP target of 120–129 mmHg in most adults (Class I) if tolerated.
Antihypertensive Medications - StatPearls - NCBI Bookshelf (treatment[3])Absolute contraindications (both classes): Pregnancy (all trimesters) because of teratogenic effects
Antihypertensive Medications - StatPearls - NCBI Bookshelf (treatment[3])bilateral renal artery stenosis or renal artery stenosis in a solitary functioning kidney
Antihypertensive Medications - StatPearls - NCBI Bookshelf (treatment[3])Dual renin-angiotensin-aldosterone system blockade (ACE inhibitor plus ARB, or either with direct renin inhibitor aliskiren) is contraindicated
Essential Hypertension - StatPearls - NCBI Bookshelf (complications[0])Hypertension has been among the most studied topics of the previous century and has been one of the most significant comorbidities contributing to the development of stroke, myocardial infarction, heart failure, and renal failure.
Essential Hypertension - StatPearls - NCBI Bookshelf (complications[1])Stroke (CVA), either ischemic or intracerebral hemorrhage
Essential Hypertension - StatPearls - NCBI Bookshelf (complications[1])Hypertensive encephalopathy
Essential Hypertension - StatPearls - NCBI Bookshelf (complications[2])The following complications have been reported with uncontrolled hypertension in multiple large-scale population trials.
Essential Hypertension - StatPearls - NCBI Bookshelf (complications[2])Coronary heart disease (CHD)
Essential Hypertension - StatPearls - NCBI Bookshelf (complications[2])Peripheral arterial disease
Essential Hypertension - StatPearls - NCBI Bookshelf (complications[2])Atrial fibrillation
Essential Hypertension - StatPearls - NCBI Bookshelf (complications[2])Aortic aneurysm

Precvičiť tému (6)

Kartičky

Vymenujte hlavné príčiny sekundárnej hypertenzie.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.

Aké základné vyšetrenia odporúča ESC 2024 u pacienta s hypertenziou na zhodnotenie poškodenia cieľových orgánov?

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.

Vymenujte komplikácie artériovej hypertenzie.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.