Risk stratification of cardiovascular events in patients with stable coronary heart disease (review). Risk stratification in the diagnosis of coronary heart disease And what does increased blood pressure lead to?
Under the term " arterial hypertension", "arterial hypertension" refers to the syndrome of increased blood pressure (BP) in hypertension and symptomatic arterial hypertension.
It should be emphasized that the semantic difference in the terms " hypertension" And " hypertension"practically none. As follows from the etymology, hyper - from the Greek above, over - a prefix indicating excess of the norm; tensio - from Latin - tension; tonos - from Greek - tension. Thus, the terms "hypertension" and " "hypertension" essentially mean the same thing - "hypertension".
Historically (since the time of G.F. Lang) it has happened that in Russia the term “hypertension” and, accordingly, “arterial hypertension” are used; in foreign literature the term “ arterial hypertension".
Hypertension (HTN) is usually understood as a chronic disease, the main manifestation of which is arterial hypertension syndrome, not associated with the presence of pathological processes in which an increase in blood pressure (BP) is caused by known, in many cases remediable causes (“symptomatic arterial hypertension”) (GFOC Recommendations, 2004).
Classification of arterial hypertension
I. Stages of hypertension:
- Hypertension (HD) stage I assumes the absence of changes in “target organs”.
- Hypertension (HD) stage II is established in the presence of changes on the part of one or more “target organs”.
- Hypertension (HD) stage III established in the presence of associated clinical conditions.
II. Degrees of arterial hypertension:
The degrees of arterial hypertension (Blood Pressure (BP) levels) are presented in Table No. 1. If the values of systolic Blood Pressure (BP) and diastolic Blood Pressure (BP) fall into different categories, then a higher degree of arterial hypertension (AH) is established. The most accurate degree of Arterial Hypertension (AH) can be determined in the case of newly diagnosed Arterial Hypertension (AH) and in patients not taking antihypertensive drugs.
Table No. 1. Determination and classification of blood pressure (BP) levels (mm Hg)
The classification is presented before 2017 and after 2017 (in brackets)| Blood pressure (BP) categories | Systolic blood pressure (BP) | Diastolic blood pressure (BP) |
| Optimal blood pressure | < 120 | < 80 |
| Normal blood pressure | 120-129 (< 120* ) | 80-84 (< 80* ) |
| High normal blood pressure | 130-139 (120-129* ) | 85-89 (< 80* ) |
| 1st degree hypertension (mild) | 140-159 (130-139* ) | 90-99 (80-89* ) |
| 2nd degree hypertension (moderate) | 160-179 (140-159* ) | 100-109 (90-99* ) |
| AH of the 3rd degree of severity (severe) | >= 180 (>= 160* ) | >= 110 (>= 100* ) |
| Isolated systolic hypertension | >= 140 |
III. Risk stratification criteria for patients with hypertension:
I. Risk factors:
a) Basic:
- men > 55 years old - women > 65 years old
- smoking.
b) Dyslipidemia
TC > 6.5 mmol/l (250 mg/dl)
LDL-C > 4.0 mmol/L (> 155 mg/dL)
HDL-C
c) (for women
G) Abdominal obesity: waist circumference > 102 cm for men or > 88 cm for women
d) C-reactive protein:
> 1 mg/dl)
e) :
- Sedentary lifestyle
- Increased fibrinogen
and) Diabetes:
- Fasting blood glucose > 7 mmol/L (126 mg/dL)
- Blood glucose after a meal or 2 hours after taking 75 g of glucose > 11 mmol/L (198 mg/dL)
II. Target organ damage (stage 2 hypertension):
a) Left ventricular hypertrophy:
ECG: Sokolov-Lyon sign > 38 mm;
Cornell product > 2440 mm x ms;
EchoCG: LVMI > 125 g/m2 for men and > 110 g/m2 for women
Rg-graphy of the chest - cardio-thoracic index>50%
b) (thickness of the intima-media layer of the carotid artery >
V)
G) Microalbuminuria: 30-300 mg/day; urine albumin/creatinine ratio > 22 mg/g (2.5 mg/mmol) for men and >
III. Associated (concomitant) clinical conditions (stage 3 hypertension)
A) Basic:
- men > 55 years old - women > 65 years old
- smoking
b) Dyslipidemia:
TC > 6.5 mmol/l (> 250 mg/dl)
or LDL-C > 4.0 mmol/L (> 155 mg/dL)
or HDL-C
V) Family history of early cardiovascular disease(among women
G) Abdominal obesity: waist circumference > 102 cm for men or > 88 cm for women
d) C-reactive protein:
> 1 mg/dl)
e) Additional risk factors that negatively affect the prognosis of a patient with arterial hypertension (AH):
- Impaired glucose tolerance
- Sedentary lifestyle
- Increased fibrinogen
and) Left ventricular hypertrophy
ECG: Sokolov-Lyon sign > 38 mm;
Cornell product > 2440 mm x ms;
EchoCG: LVMI > 125 g/m2 for men and > 110 g/m2 for women
Rg-graphy of the chest - cardio-thoracic index>50%
h) Ultrasound signs of thickening of the artery wall(carotid artery intima-media thickness >0.9 mm) or atherosclerotic plaques
And) Slight increase in serum creatinine 115-133 µmol/l (1.3-1.5 mg/dl) for men or 107-124 µmol/l (1.2-1.4 mg/dl) for women
To) Microalbuminuria: 30-300 mg/day; urine albumin/creatinine ratio > 22 mg/g (2.5 mg/mmol) for men and > 31 mg/g (3.5 mg/mmol) for women
l) Cerebrovascular disease:
Ischemic stroke
Hemorrhagic stroke
Transient cerebrovascular accident
m) Heart disease:
Myocardial infarction
Angina pectoris
Coronary revascularization
Congestive heart failure
m) Kidney disease:
Diabetic nephropathy
Renal failure (serum creatinine > 133 µmol/L (> 5 mg/dL) for men or > 124 µmol/L (> 1.4 mg/dL) for women
Proteinuria (>300 mg/day)
O) Peripheral artery disease:
Dissecting aortic aneurysm
Symptomatic peripheral artery disease
P) Hypertensive retinopathy:
Hemorrhages or exudates
Papilledema
Table No. 3. Risk stratification of patients with arterial hypertension (AH)
Abbreviations in the table below:
HP - low risk,
UR - moderate risk,
VS - high risk.
Abbreviations in the table above:
HP - low risk of arterial hypertension,
UR - moderate risk of arterial hypertension,
VS - high risk of arterial hypertension.
© S. ZH. URAZALINA, 2012 UDC 616.1-02]:005
S. Zh. Urazalina *
STRATIFICATION OF CARDIOVASCULAR RISK, CURRENT STATE OF THE PROBLEM
Federal State Institution Russian Cardiology Research and Production Complex of the Ministry of Health and Social Development of Russia, Moscow
*Urazalina Saule Zhaksylykovna, Ph.D. honey. Sciences, doctoral student. E-taD:[email protected]
Forecasting based on accounting and risk assessment occupies a central place in the system of prevention of cardiovascular diseases (CVD), including acute cardiovascular events (myocardial infarction - MI, stroke and sudden cardiac death - SCD), which remain the main causes of morbidity and mortality in developed countries. The most recent European studies show that up to 7% of all deaths in people aged 1 to 35 years are associated with SCD, a figure significantly higher than in previous studies.
At the same time, there is some inconsistency in the systematization of the list and classification of the CVD risk system among both domestic and foreign authors.
Cardiovascular risk factors, their contribution to the risk value
A risk factor is a characteristic and essential feature of an individual and his environment, which determines an increase in the likelihood of the occurrence, development and unfavorable outcome of any disease in a person.
Note that an individual risk factor determines only one of all possible causes of the development of the disease and thereby differs from the causative factor. In relation to CVD, a risk factor determines the increase in the likelihood of CVD or a complicated course (acute cardiovascular event) of an existing disease.
Based on the above definition, the most obvious dichotomies of risk factors are:
♦ internal (features of the body and personality) and external (habitat and lifestyle) factors;
♦ simple and complex (composite) factors;
♦ risk factors for morbidity and mortality;
♦ significant and insignificant (primary and secondary), i.e. factors that directly affect the risk of developing the disease, and secondary factors that modulate the values of the primary ones;
♦ changeable and unchangeable, i.e. factors that can be influenced (lifestyle) and those that cannot be changed (gender, age, genetics). Further classification of internal factors
risk of CVD leads to the identification of biochemical, physiological, psychological (features of nerve-
organization) and individual (sex, age, social, etc.) factors. External risk factors are divided into two large groups - features of a person’s lifestyle (diet, activity regime) and the environment (ecological and social factors).
In practice, patients often have two or three or more simultaneous risk factors, most of which are interrelated. The role of each of these factors may be insignificant, but due to their combined influence on each other, a high risk of developing CVD may arise. In this regard, the assessment of overall cardiovascular risk (CVR) is of great importance, the degree of which depends on the presence or absence of associated risk factors, target organ damage and associated clinical conditions. Currently, more than 200 such factors are identified.
An analysis of the available literature shows that in foreign practice, in addition to the above, an additional classification of CVD risk factors has been developed, implying their division into traditional (i.e., generally recognized, conventional) and new (novel). To date, more than 100 new and different risk factors have been proposed to improve existing stratification systems, but the 1998 and 2002 consensus conferences did not recommend any of the new factors due to the lack of convincing evidence to predict the development of complications. Therefore, when further considering CVD risk factors, we will adhere to this division.
Traditional risk factors
An analysis of the available works of domestic and foreign authors allows us to state significant discrepancies in the classification of certain CVD factors as traditional. Thus, a number of factors that have already become traditional for foreign researchers have not yet received recognition in the domestic literature. Nevertheless, an analysis of the intersections of the lists of factors proposed by different authors made it possible to identify the following list of traditional CVD risk factors (given in accordance with the classification discussed above). I. Internal risk factors 1. Physiological ♦ Increased body mass index (BMI) and obesity. Accompanying illnesses,
especially cardiovascular diseases, as a rule, develop in obese patients at a young age. This factor is associated with 44% of diabetes cases and 23% of coronary heart disease (CHD). In Russia, this factor is the most common; in the study, it was noted in 35.3% of those examined.
♦ Increased blood pressure (BP), arterial hypertension (AH). Hypertension is detected in 25-30% of the adult population of industrialized countries and is one of the most important risk factors. As a result of the study, elevated blood pressure in Russia was observed in 12.7% of those examined. Hypertension in a variety of age groups largely determines cardiovascular morbidity and mortality. Among hypertensive patients with higher blood pressure levels, the proportion of people with a low risk of death (less than 5%) from cardiovascular diseases decreases and the proportion of people with a high risk of death exceeding 5% increases. Elevated systolic blood pressure is associated with 51% of strokes (cerebrovascular diseases) and 45% of deaths from coronary artery disease.
♦ Concomitant diseases, inflammation and infections (diabetes, insulin resistance, rheumatoid arthritis, asymptomatic target organ damage). Patients with diabetes have a multiple (2-8 times) increased risk of future cardiovascular events compared to those without diabetes. 75% of all deaths due to coronary artery disease are associated with diabetes in patients. Pre-existing CVD or kidney disease (ventricular hypertrophy, thickening of the carotid artery wall, plaques, increased arterial stiffness, microalbuminuria or proteinuria, etc.) are criteria for classifying people as high and very high risk.
2. Biochemical
♦ Hypercholesterolemia. Globally, a third of CHD cases are associated with high levels of total cholesterol (TC) in the blood, which also increases the risk of CVD, stroke and other vascular diseases. Hypercholesterolemia is detected in 4.4% of those examined during clinical examination in Russia.
♦ Hyperglycemia. High blood glucose is associated with all deaths from diabetes, 22% of deaths from ischemic heart disease and 16% of deaths from stroke. Hyperglycemia is detected in 1.6% of those examined during clinical examination in Russia.
♦ Disorders of the lipoprotein (LP) spectrum, dyslipidemia, hyperhomocysteinemia. This factor is expressed in low levels of high-density lipoprotein (HDL), high levels of low-density lipoprotein (LDL) and triglycerides - TG (apolipoprotein A - apoA and apolipoprotein B - apoB). A low level of HDL characterizes a low rate of cholesterol (C) turnover at the level of the cell membrane, changing the transmembrane potential and exacerbating cellular energy deficiency. In general, a 1 mg/dL increase in HDL cholesterol is associated with a 2-3% reduction in total CVD risk. Dyslipidemia plays a primary role in the development of atherosclerosis and related CVDs. These risk factors are currently controversial and a number of researchers classify them as new.
3. Individual
A group of individual factors is characterized by their immutability, i.e., the impossibility of changing the values of their indicators.
♦ Gender. Males have a higher risk of CVD.
♦ Age. The risk of CVD morbidity and mortality increases with age.
♦ Family and individual history, for example, a family history of early coronary atherosclerosis.
♦ Genetic predisposition. Genetic factors can predetermine almost all other internal risk factors.
II. External risk factors
1. Lifestyle
♦ Tobacco smoking, including passive smoking. IHD is associated with 35-40% of all smoking-related deaths. Another 8% of deaths are attributed to secondhand smoke. The prevalence of this risk factor in Russia is 25.3%.
♦ Dietary factors. A diet high in saturated fat leads to increased cholesterol levels. Insufficient consumption of fruits and vegetables, according to some estimates, may be responsible for about 11% of deaths from coronary heart disease. Consumption of salty foods increases the risk of hypertension and, as a result, CVD.
♦ Level and nature of physical activity. Lack of physical activity and a sedentary lifestyle are the cause of up to 30% of cases of coronary artery disease and 27% of cases of diabetes. A number of recent studies challenge the traditional view of the benefits of prolonged and vigorous physical activity for the prevention of CVD. Thus, for men and women, only 30 minutes of daily walking is recommended to ensure the necessary condition of the cardiovascular system.
2. Environmental factors
♦ Psychosocial and environmental factors. The presence of depression and mental stress tends to increase cardiovascular risk. Neuropsychic stress significantly increases the heart's need for oxygen and aggravates myocardial ischemia, and is associated with the development of metabolic syndrome and the induction of ventricular arrhythmias. Stress is a recognized risk factor for acute cardiovascular events. An increased level of anxiety is observed in 10.5-21% of the population (19-20% of women and 8-10% of men), while in patients with hypertension there is an increased level of both reactive anxiety (moderate - in 48%, high - 43.5 %), and personal anxiety (moderate - in 41.5%, high - in 55.5%).
7 risk factors - smoking, high blood pressure, high BMI, hypercholesterolemia, hyperglycemia, low consumption of fruits and vegetables, and physical inactivity - account for 61% of deaths from CVDs, which, in turn, account for about 30% of all deaths in the world . The same risk factors together determine more than 75% of deaths from coronary and hypertensive heart disease. The combination of risk factors, including smoking and obesity, with low ventricular activation rate index scores is associated with the lowest rates of patient survival
Some deaths from ischemic heart disease can be prevented by lowering blood pressure or cholesterol levels, but in the presence of any form of ischemic heart disease in men over 60 years of age, traditional risk factors do not make a statistically significant contribution to the increase in mortality, and only low levels of HDL cholesterol, decreased levels apoA1 and an increase in the apoB/apoA1 ratio.
However, in modern conditions, determining traditional risk factors is not enough to predict the occurrence of cardiovascular complications. In particular, monitoring traditional risk factors alone will not identify the majority of patients who are predicted to have a heart attack in the near future. Consequently, they will not be offered adequate preventative treatment. Therefore, in recent years there has been evidence that risk stratification can be improved by assessing a number of new risk factors.
New risk factors
A significant volume of scientific medical publications over the past decade has been devoted to new factors of CVD, which are primarily promising predictors of coronary artery disease, atherosclerosis and acute cardiovascular events, as well as data for predicting the outcome of patients with CVD. Initially, new risk factors were considered only as additional ones in existing standard models for calculating risks based on traditional factors, since they are significantly correlated with them and serve to increase the accuracy of calculations in subgroups of diseases, in particular, to increase the reliability of the Bayesian criterion. However, recently a number of new factors have been proposed as candidates for the role of signs of damage to the cardiovascular system and risk factors for CVD and its complications, which can be used in risk stratification systems in individuals without clinical manifestations of CVD.
Biochemical markers of chronic inflammation, the state of electrical activity of the heart as an integral marker of the stability of the cell membranes of cardiomyocytes, immunological factors and a number of others are considered as new factors of cardiovascular risk. Based on the above division, the list of the most discussed new risk factors is as follows.
1. Biochemical (laboratory) markers
♦ Increased levels of high-sensitivity C-reactive protein (CRP). Elevated CRP levels have been shown to be an independent factor of atherosclerotic risk and adverse outcome in patients after a cardiovascular event.
♦ Increased levels of lipoprotein-associated phospholipase (LP-PLA2), which plays an important role in the pathogenesis of atherosclerotic plaque instability and is therefore a potential risk marker.
♦ Elevated levels of homocysteine, measured in serum taken from the liver. This indicator can be used as a continuous variable when assessing SSR.
♦ Drug concentration (a). The concentration of this drug in the blood determines the incidence of CVD.
It shows the level of cardiovascular risk in the adult population, regardless of age, diet, physical activity, smoking or lack thereof, alcohol consumption and gender.
♦ Lipid spectrum (apoproteins apoA, apoB, apoC, TG, LP remnants, small LDL particles, HDL subtypes, ratio of LDL cholesterol to HDL cholesterol - LDL cholesterol/HDL cholesterol).
♦ Thrombogenic/antithrombogenic factors (platelet and coagulation factors, fibrinogen, activated factor VII, plasminogen activator inhibitor-1, tissue plasminogen activator, von Willebrand factor, factor V Leiden, protein C, antithrombin III).
2. Physiological (instrumental) factors
♦ Thickness of the intima-media complex (IMT) of the carotid arteries. The indicator is measured in specialized centers using high-resolution ultrasound at points in the carotid arteries. Currently, there is a debate about the prognostic properties and uniformity of measurements of this indicator.
♦ Ankle-brachial index (ABI), calculated as the ratio of systolic blood pressure at each ankle to systolic blood pressure at the right arm.
♦ Coronary calcium index, which allows you to assess the calcium content in the walls of the coronary arteries. It is calculated in points based on the results of processing radiographic images or by measuring using electron beam computed tomography. Currently, no standards have been established for this indicator.
♦ Pulse wave propagation speed (PWV). Many studies show the high significance of this indicator as a marker of damage to the vascular wall by atherosclerosis and, consequently, the risk of morbidity and mortality from CVD, including in patients with asymptomatic atherosclerosis.
In practice, the assessment and consideration of any one risk factor is not promising and is carried out in a complex, which is reflected in a number of CVD risk assessment scales. In this case, it is advisable to consider the content and characteristics of the applied CVD risk stratification scales.
Comparative analysis of modern scales used for stratification of CVD
Currently, assessing the total risk is becoming a necessary condition for reliably determining the probability of developing cardiovascular events in the next 5-10 years in patients with existing CVD and in persons without clinical manifestations of cardiovascular pathology.
There are several models for calculating population risk. All of them are based on multivariate analysis of disease risk in large populations followed over a long period of time.
These systems certainly cannot be considered perfect. First of all, they do not take into account all currently known risk factors. The emphasis is on factors such as blood pressure level, serum total cholesterol, smoking, age and gender, and less important risk factors such as family history, obesity, overweight and others are not taken into account -
Xia. The same can be said about emerging risk factors; their use in risk assessment using known systems is not envisaged. Another problem is that most of these systems do not take into account regional characteristics, nutritional patterns and some other factors that undoubtedly affect the prognosis. Finally, a significant drawback of many systems is that they mainly take into account coronary events, MI, angina pectoris and therefore are mainly focused on determining the risk of coronary disease rather than all CVDs.
1. Framingham risk assessment scale
The Framingham Risk Score (FRS) is
a type of multidimensional intelligent assessment of the risk level of cardiovascular events based on traditional CVD factors, which are successfully used by healthcare professionals as predictors of CVD; Factor modification interventions have been shown to be effective in these models, and it is recognized that scales such as the FRS should be used to determine risk in individuals without CVD symptoms.
Many studies have demonstrated the high value of this risk assessment system in various demographic and ethnic groups. The predictive ability of FSR varies depending on the place of residence of patients. So, in Framingham itself it is 0.79 for men and 0.83 for women, and in New York it is 0.68 for both sexes. The predictive ability of the FSR in Denmark is 0.75, in Italy - 0.72, in France - 0.68, in the UK - 0.62. A review of 27 studies that used FRS scores found that the ratio of predicted to actual events ranged from an underestimation of about 0.43 in a high-risk population to an overestimation of about 2.87 in a low-risk population.
Since the FSR was compiled on the basis of a study conducted in the USA in Framingham, its data are most reliable directly for this area. However, this does not mean that it cannot be used in other regions and even countries. Many modifications of this system make it possible to use it all over the world and apply it to the black and white populations of Europe, Asian Americans, Indians, as well as residents of some Asian countries (for example, China).
Currently, there is a sufficient number of publications indicating that when using FSR data, for example in the European Region, the observed absolute risk is often significantly lower than that predicted using the Framing-Gem algorithm, i.e., the real absolute risk is overestimated.
Over the years, the European Society
Hypertension (ESH) and the European Society of Cardiology (ESC) were guided by the recommendations issued by WHO and the International Society of Hypertension (ISH), slightly adapting them to the situation in Europe. In 2003, it was decided to publish its own ESH/ESC guidelines, since the WHO/ISH guidelines are intended for countries with significantly different health care and economic conditions, and contain some diagnostic and treatment recommendations that may be insufficient.
but adequate for European countries. The 2003 ESH/ESC guidelines have been well received by the medical community and have been widely cited in the medical literature in recent years. However, since 2003, approaches to the diagnosis and treatment of hypertension have changed, which served as the basis for revising these recommendations.
For a long time, blood pressure indicators served as the only or main criterion for assessing the need for antihypertensive therapy and choosing its regimen. Although this approach was retained in the JNC 7 report, the 2003 ESH/ESC guidelines stated that total CV risk should be taken into account when diagnosing and treating hypertension. This is due to the fact that only a small proportion of patients with hypertension experience an isolated increase in blood pressure, while the vast majority of patients have additional CV risk factors.
The 2003 ESH/ESC guidelines classify overall CVR based on WHO/ISH guidelines, including patients with “normal” or “high normal” BP. This classification is retained in these recommendations. The terms “low,” “moderate,” “high,” and “very high” risk reflect the estimated risk of CVD and mortality over the next 10 years, similar to the increase in CVD estimated from the Framingham Study or the SCORE model. The term "additional" or "added" indicates that in all categories the relative risk is increased compared to the average.
Key clinical parameters that should be used for risk stratification include risk factors (demographic, anthropometric, family history of early CVD, blood pressure, smoking, glucose and lipid levels), end-organ damage, presence of diabetes mellitus and associated clinical conditions highlighted in the guidelines 2003 (see table).
Following the ESH/ESC recommendations involves the following stages of diagnostic examination: measuring blood pressure, establishing family and medical history, physical examination, laboratory tests, genetic analysis and identifying signs of damage to target organs (heart, blood vessels, kidneys, brain and fundus).
It is necessary to pay attention to the following points:
1. Metabolic syndrome is a combination of factors that are often combined with high blood pressure and significantly increase cardiovascular risk. This does not mean that it is an independent nosological form.
2. Additionally, the importance of identifying target organ damage is emphasized, since their asymptomatic changes indicate progression of shifts within the cardiovascular continuum and a significant increase in risk compared with that in the presence of risk factors alone.
3. The list of markers of kidney damage has been expanded and includes creatinine clearance, which is calculated using the Cockcroft-Gault formula, or glomerular filtration rate, calculated
System of forecast factors according to the EOAS/EOC scale 2003
Risk factors
♦ Systolic and diastolic blood pressure values
♦ Pulse blood pressure (for older people)
♦ Age > 55 years for men and > 65 years for women
♦ Smoking
♦ Dyslipidemia (cholesterol > 5.0 mmol/l or LDL cholesterol > 3.0 mmol/l) or HDL cholesterol< 1,0 ммоль/л у мужчин и < 1,2 ммоль/л у женщин или ТГ >1.7 mmol/l
♦ Fasting plasma glycemia 5.6-6.9 mmol/l
♦ Impaired glucose tolerance
♦ Abdominal obesity (waist circumference > 102 cm in men and > 88 cm in women)
♦ Family history of early CVD (< 55 лет у мужчин и < 65 лет у женщин)
Asymptomatic target organ damage
♦ ECG signs of left ventricular hypertrophy - LV (Sokolov-Lyon index > 38 mm, Cornell index > 2440 mm ms)
♦ Echocardiographic signs of LV hypertrophy (LV myocardial mass index > 125 g/m2 in men and > 110 g/m2 in women)
♦ Thickening of the carotid artery wall (IMT > 0.9 mm) or plaque
♦ kfSPV > 12 m/s
♦ Ankle-brachial index (ABI)< 0,9
♦ A slight increase in plasma creatinine levels - up to 115-133 mmol/l in men and 107-124 mmol/l in women
♦ Low estimated glomerular filtration rate (< 60 мл/ мин) или низкий клиренс креатинина (< 60 мл/мин)
♦ Microalbuminuria 30-300 mg/day or albumin/creatinine ratio > 22 mg/g in men and > 31 mg/g in women
Diabetes
♦ Fasting plasma glucose > 7.0 mmol/L with repeated measurements
♦ Post-exercise plasma glucose > 11 mmol/l
Cardiovascular diseases and nephropathy
♦ Cerebrovascular diseases: ischemic stroke, cerebral hemorrhage, transient ischemic attack
♦ Heart diseases: MI, angina, heart failure, coronary revascularization
♦ Kidney damage: diabetic nephropathy, renal dysfunction, proteinuria
♦ Damage to peripheral arteries
♦ Severe retinopathy: hemorrhages and exudates, swelling of the optic nerve nipple
according to the MORN formula, since these indicators allow a more accurate assessment of CV risk associated with renal dysfunction.
4. Microalbuminuria is currently considered a necessary component in the assessment of target organ damage, given the simplicity and relative cheapness of the method for its determination.
5. Concentric hypertrophy of the left ventricle is a structural parameter that causes a more significant increase in cardiovascular risk.
7. Risk factors include an increase in pulse wave velocity, which is an early sign of increased stiffness of large arteries, although this method is not widely available in clinical practice.
8. Low ankle-brachial index (ABI)< 0,9) - достаточно простой показатель атеросклероза и повышенного общего ССр.
9. It is recommended to evaluate target organ damage not only before (for the purpose of risk stratification), but also during treatment, since regression of left ventricular hypertrophy and a decrease in proteinuria reflect a protective effect on the cardiovascular system.
10. There is a rationale for including elevated heart rate (HR) as a risk factor because it is associated with the risk of CVD and mortality, as well as all-cause mortality. An increase in heart rate increases the risk of developing hypertension and is often combined with metabolic disorders and metabolic syndrome. However, given the wide range of normal resting heart rate values (60–90/min), it is currently impossible to identify indicators that could improve the accuracy of stratification of total heart rate.
11. The main criteria for identifying high and very high risk groups in the scale under consideration are:
♦ systolic blood pressure > 180 mm Hg. Art. and/or diastolic blood pressure > 110 mm Hg. Art., as well as systolic blood pressure > 160 mm Hg. Art. in combination with low diastolic blood pressure< 70 мм рт. ст.;
♦ diabetes mellitus;
♦ metabolic syndrome;
♦ existing CVD or kidney disease;
♦ three factors of SSR or more;
♦ at least one of the following indicators of asymptomatic target organ damage: electrocardiographic (especially with overload) or echocardiographic signs of left ventricular hypertrophy; sonographic signs of thickening of the carotid artery wall or plaque; increased arterial stiffness; moderate increase in serum creatinine levels; decreased glomerular filtration rate or creatinine clearance; microalbuminuria or proteinuria. It should be noted that the presence of multiple
risk factors, diabetes mellitus or target organ damage clearly indicates a high risk, even with high normal blood pressure.
The proposed recommendations have specific conceptual limitations. Thus, overall SVR depends largely on age. In young adults (especially women), the risk is rarely high even when more than one risk factor is present, but their relative risk (compared with their peers) is clearly increased. In contrast, most people over 70 years of age often have a high overall risk, although it is only slightly increased compared with that of patients of the same age. As a result, funds are spent primarily on older people who have limited life expectancy despite treatment, while little attention is paid to younger people with a high relative risk. If left untreated, long-term exposure to risk factors can lead to partially irreversible changes and a possible reduction in life expectancy.
relative risk. For this purpose, the HeartScore index (www.escardio.org) can be used, taking into account the recommendations for the prevention of CVD in clinical practice proposed by the fourth joint working group of European societies. 3. SCORE scale (2003)
The easiest to use is the currently proposed European SCORE system. This system, adopted in 2003 by the European Society of Cardiology, and the results of its use were already reported at the European Congress of Cardiology in 2005, was created based on the results of 12 epidemiological European studies, including Russian ones, including 250,000 patients, 3 million person-years of observation and recording of 7000 fatal cardiovascular events.
The system is presented in two tables for calculating risk in countries with low and high levels of risk. In addition to color division by risk level, each cell of the graph contains a number for a more accurate quantitative risk assessment. The scale includes such CVD factors as age, gender, TC level, systolic blood pressure and smoking. The risk indicator is the probability of death from any CVD in the next 10 years of the patient’s life. The risk is considered low (< 1%) и средним, если при проекции данных пациента на карту SCORE он составляет менее 5%, высоким, если он находится в пределах 5-9%, и очень высоким, если равен 10% или более.
This system is more progressive, since it does not have some of the disadvantages of other systems. First, it can be used to calculate CV risk, not just coronary disease risk, which expands its application. It is also the first to attempt to take into account regional differences by offering different risk calculation tables for different high- and low-risk regions of Europe.
A significant difference in this system is that risk indicators were calculated not according to the Framingham study, but based on data from 12 European epidemiological studies.
Features of the SCORE system include its applicability only to individuals without clinical manifestations of CVD, ease of use, and the availability of special versions for countries with high and low cardiovascular mortality. For countries classified as high risk (countries of Northern and Eastern Europe, former Soviet republics), high risk exceeds 5%, moderate (intermediate) is 2-4%, and low is less than 2% probability of death from any CVD. over the next 10 years. However, this system only considers the risk of a fatal outcome of the disease.
The SCORE risk assessment scale, included in the European recommendations for the prevention of CVD in clinical practice, 2003, despite all the obvious advantages, has a number of limitations. The risk of CVD, calculated by SCORE, may be underestimated by: examination of an elderly patient, preclinical atherosclerosis, unfavorable heredity, decreased HDL cholesterol levels, increased levels of TG, CRP, apoB/Lp(a), obesity and physical inactivity. Despite this fact, we can conclude that in
Doctors have a simple tool for determining the total risk of fatal CVD, which can be used directly at the workplace during an outpatient appointment - the SCORE scale.
4. ATP III scale
The National Cholesterol Education Program Adult Treatment Panel III is designed as a tool to assess the risk of CVD severity over a 10-year period based on the FRS using population data and cost-effectiveness assessments.
The concept of vascular age was tested in studies that preceded this program. It was noted that ART III identifies women and young men at low risk of CVD (< 10%), даже если они имеют несколько факторов риска.
The latest version of NCEP ATP III (based on 5- and 10-year studies) included CV risk factors such as age (for men over 45 years old, for women over 55 years old), gender, total cholesterol level, HDL cholesterol, systolic blood pressure and smoking. TC levels were included in this system because the Framingham study database demonstrated a higher association with CV risk than LDL levels. Diabetes mellitus according to this system is regarded as equivalent to CVD, so patients with this disease are classified as high risk.
What's different about this system is that it distinguishes "medium-high" risk (defined as a 10% risk of 10-year mortality) as opposed to high risk (20% risk). This category, according to the authors, is necessary to improve the quality of prevention and treatment of CVD at the level of both medical care and healthcare organization.
For almost all combinations of risk factors, even extreme values, nonsmoking men under 45 and virtually all women under 65 have a 10-year risk of less than 10%. Thus, many high-risk young patients are included in the population who do not require preventive therapy. Such data certainly requires reclassification to more reliably determine the level of risk.
The system for identifying risk groups in the ATP III program coincides with the system for identifying risk groups in the SCORE scale.
NCEP-ATP III notes the need and high importance of searching for biomarkers that increase or decrease HDL levels.
5. PROCAM model
This model, recommended by the International Atherosclerosis Society for calculating risk, is based on the results of an epidemiological study of 40,000 patients. With the help of new algorithms, it has become possible to recognize the preclinical stage of atherosclerosis. The PROCAM score is more relevant for use in patients with metabolic disorders or diabetes mellitus. This system takes into account age, smoking, LDL and HDL levels, systolic blood pressure, family history of CVD (MI), diabetes mellitus and TG levels. In this case, the points assigned for each risk factor are calculated: age - from 0 to 26, LDL cholesterol level - from 0 to 20, HDL cholesterol - from 0 to 11, TG - from 0 to 4, smoking - from 0 to 8, diabetes mellitus - from 0 to 6, heredity -
from 0 to 4, systolic blood pressure - from 0 to 8. Ultimately, the data is added up and the result is checked against a table that indicates the 10-year risk for a given number of points.
6. D'Agustino risk stratification system Recent publication by R. D'Agostino et al. opens up the possibility of introducing into clinical practice a new unified algorithm for assessing CVD risk. The authors believe that this algorithm is a universal tool for assessing cardiovascular risk and will be useful for general practitioners. The study authors developed an algorithm for estimating total cardiovascular risk separately for men and women. According to the data obtained, the risk of developing CVD was determined by factors such as age, total cholesterol level in the blood, HDL cholesterol levels, systolic blood pressure levels, use of antihypertensive drugs, smoking, and diabetes mellitus. Depending on the presence (severity) of a particular factor, scores were calculated, the sum of which allows us to determine the degree of risk and the “cardiovascular age” of the patient.
This scale allows you to approximately estimate the cardiovascular risk even at the first visit to the doctor and determine the need to prescribe additional studies. However, this algorithm for determining CVR has not taken root in real practice due to low accuracy, due to the fact that it is purely indirect in nature, since it does not contain a single parameter that directly describes the properties of the arterial wall.
Thus, in modern conditions, determining traditional risk factors is not enough to predict the occurrence of cardiovascular complications. Therefore, it is promising to use a number of new factors as candidates for the role of signs of damage to the cardiovascular system, which can be used in risk stratification systems in individuals who do not have clinical manifestations of CVD. The modern CVS stratification systems considered cannot be considered perfect, since they do not take into account all currently known risk factors, but focus on traditional factors. At the same time, the most promising in terms of refinement and use of new CVD risk factors is the scale of the EHS/ESC Recommendations (2003, 2007).
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Risk stratification often used to assess risk and aid decision making. This approach typically takes data from statistical models that identify prognostic factors and integrates them into various risk scoring systems to help clinicians make decisions. In recent years, many risk calculation systems have emerged to quickly assess a patient's condition.
For example, TIMI risk calculation system for patients with unstable angina (UA) or without ST elevation, uses 7 available indicators to determine the risk of tornadoes and ischemic events. The risk range varies depending on the number of detected risk factors: from 5% (presence of 0-1 factor) to 41% (presence of 6-7 factors).
IN research When discussing risk stratification, it is important to consider the possibility of applying the same approaches and systems for calculating risk to a specific population, if in practice they are used only in patients. Prognostic indicators should be selected regardless of the outcome. The final results (outcomes) and time parameters must be available.
Should be clear be the very idea of stratification. It is necessary that increased accuracy in risk assessment have positive consequences, because lack of benefit is similar to ordering examinations that are not relevant for therapy.
The risk-treatment paradox. In some studies, a risk-treatment paradox was observed, in other words, patients at higher risk were significantly less likely to receive interventions that were expected to be successful. This is an example of a paradoxical approach, because high-risk patients would benefit most from risk-reducing interventions. This follows from the consideration that the relative risk reduction is similar in groups with different baseline risks.
When assessing the effect interventions Additional attention must be paid to the final results of the study and the period of time over which the observation was carried out. In articles devoted to patients with CVD, the emphasis is often placed only on cardiovascular events, incl. cardiovascular death. Of greater interest, however, is overall all-cause mortality.
If intervention prevents cardiovascular death but leads to death from other causes, then such intervention is of no value to the patient. This is especially important for elderly patients with comorbidities with competing risks. Moreover, the prospect of reduced mortality in the near future after surgery may not be of value to the patient if comorbidities or complications significantly reduce QoL over that time period. QoL and health status issues are often ignored in research, although they are important for patients. This narrow, specific view of study outcomes does not allow for a comprehensive evaluation of the intervention.
Arises problem and with the assessment of a large number of final results, because this may increase the likelihood of false-positive results. Another important aspect associated with trial results is that intermediate (or surrogate) endpoints such as ejection fraction (EF) are not always consistent with hard endpoints such as survival.
By definition, sudden death is considered to be death from which the first symptoms of deterioration of the patient’s condition are separated by a period of no more than 1 hour, and in real practice this period is often measured in minutes.Prevalence. Causes
Hundreds of thousands of sudden deaths are recorded around the world every year. In developed countries, its frequency is 1-2 cases per 1000 population per year, which corresponds to 13-15% (according to some sources up to 25%) of all cases of natural death. Sudden cardiac death (SCD) is the first and often the only manifestation of coronary artery disease, in which 50% of deaths are sudden, and among patients with chronic heart failure, more than half die suddenly.Pathophysiology
Sudden cardiac death risk stratification
The close connection of sudden cardiac death with some forms of ventricular cardiac arrhythmias makes it necessary to carry out their risk stratification, i.e. ranking according to the risk of developing ventricular fibrillation. The first attempt at such stratification was made by B. Lown and M. Wolf, who proposed in 1971. gradation classification of ventricular arrhythmias recorded with HM ECG. The classification distinguishes the following gradations:- Gradation 0 - there are no ventricular cardiac arrhythmias.
- Gradation 1 - rare (no more than 30 per hour) monotopic ventricular extrasystole.
- Gradation 2 - frequent (more than 30 per hour) monotopic ventricular extrasystole.
- Gradation 3 - polytopic ventricular extrasystole.
- Gradation 4A - two consecutive (paired) ventricular extrasystoles.
- Gradation 4B - several in a row (three or more) ventricular ectopic contractions - “jogs” of ventricular tachycardia.
- Gradation 5 - early ventricular extrasystole of the R/T type.
- Benign ventricular arrhythmias include ventricular extrasystole, often single (there may be other forms), asymptomatic or asymptomatic, but most importantly, occurring in individuals who do not have signs of heart disease (“idiopathic” ventricular arrhythmias). The prognosis for these patients is favorable, due to the very low likelihood of fatal ventricular arrhythmias (eg, ventricular fibrillation), no different from that in the general population, and, from the standpoint of preventing sudden cardiovascular death, they do not require any treatment. All that is necessary is dynamic monitoring of them, because, at least in some patients, PVCs may be the first clinical manifestation, the debut of a particular cardiac pathology.
- The fundamental difference between potentially malignant ventricular arrhythmias and the previous category is the presence of organic heart disease as the cause of their occurrence. Most often, these are various forms of coronary artery disease (the most significant is previous myocardial infarction), heart damage due to arterial hypertension, primary myocardial diseases, etc. Of particular additional importance are a decrease in the ejection fraction of the left ventricle and symptoms of chronic heart failure. These patients with ventricular extrasystole of various gradations (a potential triggering factor for ventricular tachycardia and VF) have not yet had paroxysms of VT, episodes of ventricular flutter or VF, but the likelihood of their occurrence is quite high, and the risk of SCD is characterized as significant. Patients with potentially malignant ventricular arrhythmias require treatment aimed at reducing mortality, treatment based on the principle of primary prevention of SCD.
- Sustained paroxysms of VT, as well as episodes of VT or VF experienced due to successful resuscitation (i.e., sudden arrhythmic death) in people with organic heart disease form the category of malignant ventricular arrhythmias. They manifest themselves with the most severe symptoms in the form of palpitations, fainting, and a clinical picture of circulatory arrest. The prognosis for the life of these patients is extremely unfavorable, and their treatment should aim not only at eliminating severe arrhythmias, but also at prolonging life (secondary prevention of SCD).
- unsustained ventricular tachycardia
- sustained ventricular tachycardia
- cardiac arrest due to flutter and/or ventricular fibrillation.
Prevention of sudden cardiac death
Patients who have undergone successful resuscitation for ventricular VF, as well as patients with persistent paroxysms of VT occurring with hemodynamic disturbances (provided that these cardiac arrhythmias manifested themselves outside the acute phase of myocardial infarction or arose against the background of other severe chronic heart pathology) need to use automatic implantable cardioverter-defibrillators (ICDs) as a means of secondary prevention of SCD, providing a significant reduction in mortality in these categories of patients by reducing the incidence of SCD.Thus, for the purpose of secondary prevention of SCD, the use of ICD is indicated:- patients who have experienced circulatory arrest caused by ventricular VF or VT, after excluding other causes or reversible factors;
- patients with organic heart disease and persistent paroxysms of VT, regardless of the severity of their hemodynamic manifestations;
- patients with fainting of unknown origin, if during EPS induction of VF or VT with acute, severe hemodynamic disturbances is achieved.
- patients with left ventricular ejection fraction (LVEF)<35% после инфаркта миокарда (не менее чем через 40 дней), при наличии недостаточности кровообращения II–III функционального класса (ФК), по классификации NYHA, или с ФВЛЖ <30%, в те же сроки после инфаркта миокарда, при наличии недостаточности кровообращения I ФК по NYHA;
- patients with LVEF<35% на фоне дилатационной кардиомиопатии, при наличии недостаточности кровообращения II–III ФК по NYHA;
- patients with LVEF<40% после инфаркта миокарда, с эпизодами неустойчивой ЖТ, если при проведении ЭФИ достигается индукция ФЖ или устойчивой ЖТ.
In patients with hypertension, the prognosis depends not only on blood pressure levels. The presence of associated risk factors, the degree of involvement of target organs in the process, as well as associated clinical conditions are no less important than the degree of increase in blood pressure, and therefore stratification of patients depending on the degree of risk has been introduced into the modern classification.
It is advisable to abandon the term “stage”, since in many patients it is not possible to register the “stages” of the development of the disease. Thus, instead of the stage of the disease, determined by the severity of organ damage, a division of patients according to the degree of risk has been introduced, which makes it possible to take into account a significantly larger number of objective parameters, facilitates the assessment of individual prognosis and simplifies the choice of treatment tactics.
Risk stratification criteria
|
Risk factors |
Target organ damage |
Associated clinical conditions |
Men over 55 years of age; Women over 65 years of age; |
Left ventricular hypertrophy (EchoCG, ECG or radiography); Proteinuria and/or creatinemia 1.2-2 mg/dl; Ultrasound or radiological signs of atherosclerotic plaque; Generalized or focal narrowing of the retinal arteries. |
CEREBROVASCULAR DISEASES Ischemic stroke; Hemorrhagic stroke; Transient ischemic attack; HEART DISEASES Myocardial infarction; Angina; Coronary revascularization; Congestive heart failure; KIDNEY DISEASES Diabetic nephropathy; Renal failure (creatinine more than 2 mg/dl); VASCULAR DISEASES Dissecting aortic aneurysm; Symptomatic damage to peripheral arteries; HYPERTONIC RETINOPATHY Hemorrhages or exudates; Papilledema; DIABETES |
Classifications of essential hypertension Classification of stages of arterial hypertension (according to WHO recommendations)
StageI. No target organ damage.
StageII. Presence of at least one of the following signs of target organ damage:
Left ventricular hypertrophy, detected mainly by echocardiography, as well as by radiography (according to Makolkin V.I., 2000, the method of spatial quantitative vectorcardiography is more sensitive than echocardiography);
Local or generalized narrowing of the retinal arteries;
Microalbuminuria (urinary excretion of more than 50 mg/day of albumin), proteinuria, a slight increase in plasma creatinine concentration (12-2.0 ml/dl);
Ultrasound or angiographic signs of atherosclerotic lesions of the aorta, coronary, carotid, iliac or femoral arteries.
StageIII. Presence of symptoms of dysfunction or damage to target organs:
Heart: angina pectoris, myocardial infarction, heart failure;
Brain: transient cerebrovascular accidents, stroke, hypertensive encephalopathy;
Ocular fundus: hemorrhages and exudates with or without papilledema;
Kidneys: plasma creatinine concentration more than 2 mg/dl, chronic renal failure;
Vessels: dissecting aneurysm, symptoms of occlusive lesions of peripheral arteries.
Name of the disease -"hypertension" or "essential hypertension".
It seems incorrect to use the term “arterial hypertension” without specifying its origin. Flow stage –
I, II, III according to WHO classification. Specific indication of target organ damage
(left ventricular hypertrophy, fundus angiopathy, damage to cerebral vessels, kidney damage). Indication of associated risk factors
(hyperlipidemia, hyperuricemia, obesity, hyperinsulinism).
The degree of increase in blood pressure.
Examples of diagnosis formulation
Essential hypertension stage I.
Essential hypertension, malignant course.