Notes on pathophysiology of arterial hypertension and diabetes mellitus.
Arterial hypertension: epidemiology, pathogenesis, risk factors, classification, and therapy.
Diabetes mellitus: pathogenesis and classification
ARTERIAL HYPERTENSION, DIABETES MELLITUS
ARTERIAL HYPERTENSION
EPIDEMIOLOGY AND RISKS
GENERAL OVERVIEW
The arterial hypertension is the most important modifiable risk factor for all-cause morbidity and
mortality worldwide and it is associated with an increased risk of cardiovascular disease (CVD). In
2015, 8.5mln of deaths were associated with
hypertension, 88% of which were in low and
middle-income countries. The arterial
hypertension is nowadays controlled and
treated easily. The management is based on
lifestyle change, while the treatment is
variable, and it is becoming more personalised.
In the pre-industrial societies, BP levels had
narrow distributions with mean values that
changed little with age and averaged around
115/75mmHg, a value that probably
represents the normal BP for humans. In most contemporary societies, the systolic BP levels rise
steadily and continuously with age in both men and women. It is observed that about 3.5bln of people
have non-optimal systolic BP (>110-115mmHg) and 900mln have a systolic BP of more than
140mmHg.
EPIDEMIOLOGICAL STUDIES
The increased in the systolic BP can be associated with an increased in longevity, and due to several
environmental factors, which are:
• Excessive sodium intake: it is a
consequence of industrialisation; more
industrial food, preservatives, and
canned food are eaten.
• Insufficient intake of potassium: it is
linked to high sodium intake.
• Overweight and obesity.
• Alcohol intake.
• Physical inactivity.
The developed countries have a lower incidence
compared to developing countries. In a
longitudinal study conducted over 40 years
shown that the hypertension is decreasing in the
developed countries, and it is increasing in
developing countries (e. g. India, China). The
reason for this behaviour is related to two factors,
which are diet and treatment. In developed
countries prevention, changes in the lifestyle,
and treatment are better performed. Individuals
try to buy healthier and fresher food rather than processed or canned food. Secondly, more drugs
have been developed to treat hypertension, and they can be chosen according to the type of patient
(personalised patients).
On the other hand, developing countries are now becoming richer and the availability of processed
food and lack of sufficient therapy have increased the number of patients suffering from arterial
hypertension.
, RISKS FOR HYPERTENSION
The hypertension is the most common prevalent risk factor for different diseases, which are:
• Cardiovascular disease: it is an indirect effect, since hypertension is a risk factor for
atherosclerosis, which can lead to
further consequences, which are:
Coronary heart disease:
ischemia, infarction, angina
pectoris.
Heart failure: it is a
consequence of myocardial
infarction, in which the heart
does not restabilise its normal
function.
Stroke.
Peripheral artery disease.
• Cerebral haemorrhage: it is a direct
effect, in which high pressure in the
cerebral vessels may trigger the
alteration of the structure of them;
arteries of the circle of Willis are
extremely sensible to high pressure; this results in different diseases, which are:
Hyperintensive microangiopathy: it can create a dilation of the vessels, resulting in
an aneurysm (Charcot-Bouchard aneurysm, microaneurysm); there is a high risk of
breakage, causing cerebral haemorrhage; another condition is the lipohyalinosis,
which consists in a eosinophilic material deposits in the connective tissue of the deep
penetrating arteries.
Cerebral amyloid angiopathy: it results in fibrinoid necrosis and weakening of arterial
wall.
Coagulopathy for concomitant treatment.
• Chronic kidney disease: it results in nephropathies.
• Cognitive impairment: it is caused by continuous ischemic and vascular events, and it is called
multivascular dementia.
Overall, the hypertension is the leading contributor to all-cause mortality and disability worldwide.
The increase in the BP increases the risk of developing CVD. It was performed a study that want to
identify the distribution of the incidence of CVD mortality related to hypertension. All the other risk
factors for CVD (e. g. cholesterol levels, smoking, obesity, age, etc.) were
adjusted. It was seen that the highest incidence of infarction is not in
individuals with severe high BP, but rather in people with moderate
high pressure. This is related to the higher number of individuals that
fit in the second group. For that reason, even moderate high BP
becomes to be more concerned, and therapy is given even in this
category of patients. Through this new approach the number of
patients suffering of CVD or dying due to heart attack related to
hypertension reduce in developed countries.
BLOOD PRESSURE AND REGULATION
PHYSIOLOGICAL REGULATION
The blood pressure is determined by the cardiac output and the total peripheral resistance. The
maintenance of the physiological BP depends on the interplay of five main system, which are:
• RAAS: it is the main regulator of the BP; the renin is released when a decreased in the BP or a
decreased in sodium in the renal tubule is detected; the angiotensin II has a hyperintensive
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