How to treat arterial hypertension correctly and prevent a cerebro-vascular attack (cerebro-vascular accident)

 Arterial hypertension is one of the most widespread causes of the development of impairment of cerebral blood circulation, with the level of systolic arterial pressure (SAP) having more prognostic value than that diastolic arterial pressure (DAP). Patients with high blood pressure run the risk of developing all clinical forms of ischemic heart disease (IHD) including stenocardia, myocardial infarction and sudden death, and the level of risk is proportional to the severity of the arterial hypertension. This proves the existence of a relationship of cause and effect between arterial hypertension and IHD.

 The brain is one of the target organs in high blood pressure. Cerebro-vascular complications in many respects define the fate of patients with arterial hypertension. It is the biggest reason for permanent disability and lethality. The functional and structural changes of the cerebral arteries in patients with a long history of the disease could lead to various neurological and mental dysfunction and contribute to the development of cerebro-vascular accidents or transitional impairment of blood circulation. Effective hypotensive therapy prevents the development of this disorder in hypertension patients. It has to be noted that in some cases hypotensive therapy causing an excessive fall in the arterial pressure can cause the development of ischemia of the brain, or aggravate it, for example in the acute phase of cerebro-vascular ischemia. In this connection, it is worth taking note of the acute and chronic effects of hypotensive medications. There are some differences in the factors of development of atherothrombic (mainly ischemic) cerebro-vascular accident on the one hand, and hemorrhagic cerebro-vascular accident and sub-arachnoidal haemorrhages on the other. Arterial hypertension, cigarette smoking and alcohol abuse (more than 60grams a day) increases the risk of development of all three types of cerebro-vascular accident. The connection between arterial hypertension and the development of a cerebro-vascular accident is closer than to the development of IHD. Absolute risk of cerebro-vascular accident increases with age. However, dependence of a cerebro-vascular accident on the level of DAP is more closely linked to patients younger than 45 years of age in comparison to those older.

Thus, for the prevention of a cerebro-vascular accident it is necessary to lower elevated levels of diastolic and, in particular, systolic arterial hypertension, not condoning a rise in pulse arterial pressure. It has been established that hypotensive therapy approximately equally reduces the risk both of the first and a repeated cerebro-vascular accident.

Question: What is the most substantial in the prevention of cerebro-vascular accident? Can one consider controlling the arterial pressure the most important move?

There are risk factors in the development of cerebro-vascular accident which are not that easy to exert an influence on, for example age or the congenital structure of the cerebral vessels. However, the influence of other factors can really be reduced. First of all, it is the level of arterial pressure. The control of arterial pressure is particularly important in secondary prevention i.e. repeated cerebro-vascular accidents, whose prognosis is much worse. In order to decrease the risk of cerebro-vascular accident it is strategically vital to carry out massive prophylaxis as well as prophylaxis among high risk groups. Massive measures which are based on promoting healthy lifestyles are quite simple (giving up smoking, physical activeness, positive emotions, diet), has led to a substantial decrease in the frequency of arterial hypertension in a number of Western European countries. In high risk groups for example, with a clear familial predisposition or early atherosclerosis, there is the need to control the major risk factors (arterial hypertension, IHD, diabetes, the blood cholesterol content as well as body weights, excessive alcohol consumption).

Question: Is it important by which means hypotensive effect is reached in order to prevent cerebro-vascular accident?

For the prevention of cerebro-vascular accident it is necessary that the level of arterial pressure be controlled, and not just be lowered. A sharp fall in the level of arterial pressure – just like a sharp rise – is one of the risk factors in the development of cerebro-vascular accident. Therefore it is necessary to control the arterial pressure without daily fluctuations. One also has to take note of the need to improve the cerebral blood circulation. In such situations it is pertinent to prescribe medications that both stabilize arterial pressure and at the same time have a positive influence on the microcirculation of vessels of the brain.

Question: Which is easier to prevent – ischemic or hemorrhagic cerebro-vascular accident - is easier to prevent?

Hemorrhagic cerebro-vascular accident is strictly connected to a significant rise in arterial pressure and an alteration of the cerebral vessels (aneurysms, alterations owing to large atherosclerotic flurring of the walls of the cerebral blood vessels). Ischemic cerebro-vascular accident represents an acute stage of ischemic disease of the brain. It is easier to predict its development and find the appropriate treatment for it.

Question: Is a rise in the morning arterial pressure in itself a predictor of cerebro-vascular accident?

Clinical examination of patients with high and stoic arterial pressure has shown that the prevention of an excessive rise in the arterial pressure can prevent target organs being affected as well as complications. The prevention of a high rise in arterial pressure with medication can reduce the risk impairment of cerebral blood circulation.

Thus, it is worth noting that the most frequent mistake by therapists is the striving, no matter what it takes, to lower the blood pressure to a conditionally-set norm. However, high blood should be normalized gradually while taking the age and sex of the patient in question.

By Dr. Z.N. Ligai, former leading scientist and head of the unit of Hypertension, Myology and Cardiac Insufficiency at the Scientific Research Institute of Cardiology and Internal Diseases.