Baltojo chalato hipertenzija – dažna, bet per menkai įvertinta būklė

Baltojo chalato hipertenzija – dažna, bet per menkai įvertinta būklė

Įvadas

 

Terminas baltojo chalato hipertenzija klinikinėje praktikoje vartojamas jau seniai. Juo apibūdinama būklė, kai gydytojo kabinete nuolat išmatuojamas padidėjęs arterinis kraujo spaudimas (AKS), tačiau matuojant namų aplinkoje nustatomas normalus AKS (1). Asmenys, kuriems diagnozuojama baltojo chalato hipertenzija, skiriasi nuo nuolatine arterine hipertenzija sergančių pacientų ne tik AKS vertėmis, išmatuotomis namuose ir gydytojo kabinete. Pastebėta, kad baltojo chalato hipertenzija dažniau pasireiškia moterims ir jaunesnio amžiaus pacientams, šia hipertenzijos forma sergantys pacientai rečiau būna nutukę.

Skirtinguose literatūros šaltiniuose nurodomas skirtingas sergamumo baltojo chalato hipertenzija dažnis. Šiuos skirtumus lemia demografiniai ir klinikiniai ypatumai, nevienodos namuose išmatuoto AKS normos ribos, matavimo metodika ir kt. Vis dėlto dauguma ekspertų pripažįsta, kad baltojo chalato hipertenzija yra dažna būklė, diagnozuojama 25–30 proc. ambulatoriniuose hipertenzijos gydymo centruose apsilankančių pacientų (2). Išanalizavus Ispanijos ambulatorinio kraujo spaudimo registro (angl. Spanish Ambulatory Pressure Monitoring Registry) duomenis, baltojo chalato hipertenzija buvo diagnozuota ketvirtadaliui vaistais nuo AKS negydomų pacientų (3). AKS matavimo metodo svarbą diagnozuojant baltojo chalato hipertenziją pagrindžia epidemiologinio PAMELA (it. Pressioni Arteriose Monitorate E Loro Associazioni) klinikinio tyrimo rezultatai. Klinikinį tyrimą PAMELA vykdė Italijos mokslininkų komanda. Juo siekta nustatyti ambulatorinio ir namuose išmatuoto AKS normos ribas bendrojoje populiacijoje. Vertinant tik namuose išmatuoto AKS vertes, baltojo chalato hipertenziją buvo galima diagnozuoti 9 proc. asmenų bendrojoje populiacijoje. Pasitelkus paros AKS stebėsenos sistemą, baltojo chalato hipertenzija buvo diagnozuota 12 proc. tyrimo dalyvių (4).

Mokslininkų sukaupta patirtis ir žinios šiandien nebeleidžia žvelgti į baltojo chalato hipertenziją kaip į nereikšmingą paciento ypatybę. Pateikiama vis daugiau duomenų, pagrindžiančių reikšmingą baltojo chalato hipertenzijos vaidmenį didinant širdies ir kraujagyslių ligų riziką.

Šiame straipsnyje plačiau apžvelgiami su baltojo chalato hipertenzija susiję pavojai, pateikiamas šiuolaikinis požiūris apie šią dažną, bet per menkai įvertintą ligą.

 

Padidėjusi hipertenzijos rizika

 

Asmenys, kuriems nustatoma baltojo chalato hipertenzija, turi didesnę riziką per 10 metų susirgti pirmine arterine hipertenzija. Remiantis namuose ir gydytojo kabinete išmatuotomis AKS vertėmis, klinikinio tyrimo PAMELA dalyviams buvo diagnozuojama baltojo chalato hipertenzija. Šių tiriamųjų ilgalaikio stebėjimo rezultatai atskleidė, kad asmenys, kuriems buvo diagnozuota baltojo chalato hipertenzija, patyrė 2,5 karto didesnę riziką per 10 metų susirgti pirmine arterine hipertenzija, kai tiek gydytojo kabinete, tiek namuose išmatuojamas didesnis nei normalus AKS. Ši rizika nepriklausė nei nuo tiriamojo lyties, nei nuo amžiaus (5).

Neseniai baltojo chalato hipertenzijos nulemta nuolatinės hipertenzijos rizika buvo įvertina Suomijoje. Šioje šalyje buvo atliktas valstybinio masto populiacijos tyrimas, kurio dalyviai stebėti 11 metų (6). Paaiškėjo, kad 18 proc. asmenų, kurių AKS tiek namuose, tiek gydytojo kabinete buvo normalus, per 11 metų susirgo nuolatine arterine hipertenzija, o net 52 proc. tiriamųjų, kuriems diagnozuota baltojo chalato hipertenzija, per šį stebimąjį laikotarpį susirgo nuolatine arterine hipertenzija. Šio tyrimo rezultatai atskleidžia, kad baltojo chalato hipertenzija sergančių pacientų patiriama rizika susirgti nuolatine hipertenzija yra beveik 3 kartus didesnė nei tų, kuriems ši būklė nenustatoma.

 

Metabolinių sutrikimų rizika

 

Per keletą pastarųjų metų mokslininkams pavyko sukaupti nemažai įrodymų, pagrindžiančių baltojo chalato hipertenzijos ir kitų širdies ir kraujagyslių sistemos ligų ryšį. Asmenų, kuriems diagnozuojama baltojo chalato hipertenzija, kraujyje nustatoma didesnė cholesterolio, trigliceridų, šlapimo rūgšties ir gliukozės koncentracija, jų liemens apimtis ir kūno masės indeksas yra didesni, be to, jiems dažniau diagnozuojamas metabolinis sindromas (7). Šie metaboliniai pokyčiai sąveikauja su AKS padidėjimu ir gali nulemti organų taikinių pažeidimą. Tokie procesai gali pažeisti širdį, kraujagysles ir inkstus. Ypač svarbų vaidmenį šioje rizikos veiksnių grandinėje atlieka gliukozės apykaitos sutrikimas. Pastebėta, kad sergantys baltojo chalato hipertenzija pacientai gerokai dažniau suserga cukriniu diabetu, jiems dažniau diagnozuojamas gliukozės tolerancijos sutrikimas. Gliukozės apykaitą organizme sutrikdančios būklės yra nepriklausomi širdies ir kraujagyslių ligų rizikos veiksniai. Jau minėto klinikinio tyrimo PAMELA išvadose pabrėžiama, kad nustačius baltojo chalato hipertenziją gerokai padidėja rizika per 10 metų susirgti cukriniu diabetu. Maža to, autoriai nurodo, kad ši rizika yra panaši į tų asmenų, kurie serga pirmine arterine hipertenzija (4, 5, 7).

 

Organų taikinių pažeidimas

 

Pateikiama vis daugiau duomenų apie baltojo chalato hipertenzijos nulemtą subklinikinį organų taikinių pažeidimą. Šiandien manoma, kad baltojo chalato hipertenzija, kalbant apie organų taikinių pažeidimą, užima tarpinę poziciją tarp normalaus AKS ir nuolatinės hipertenzijos. Neseniai atliktos metaanalizės rezultatai atskleidė, kad sergant baltojo chalato hipertenzija progresuoja morfologiniai ir funkciniai širdies pokyčiai – didėja miokardo masės indeksas, sumažėja ankstyvojo ir vėlyvojo kairiojo skilvelio pildymosi per mitralinį vožtuvą diastolės metu santykio reikšmė (kairiojo skilvelio diastolinės funkcijos pokyčiai), didėja kairiojo prieširdžio dydis (8). Vis dėlto organų taikinių pažeidimas neapsiriboja tik širdies pažaida – pažeidžiama visa kraujotakos sistema. Pastebėta, kad sergant baltojo chalato hipertenzija pažeidžiamos miego arterijos, sustorėja bendrosios miego arterijos intimos ir medijos sluoksnis (9). Patofiziologiniu požiūriu baltojo chalato hipertenzija yra tartum tarpinė būklė tarp normalaus AKS ir nuolatinės hipertenzijos, kuriai būdingi saviti morfologiniai širdies ir kraujagyslių sistemos pokyčiai.

Gerokai mažiau žinoma apie didžiųjų arterijų standumo pokyčius, subklinikinį inkstų ir tinklainės pažeidimą sergant baltojo chalato hipertenzija. Kai kurie autoriai susiejo baltojo chalato hipertenziją su padidėjusiu pulsinės bangos greičiu, mikroalbuminurija (ankstyvasis inkstų pažeidimo žymuo) ir net retinopatija.

 

Širdies ir kraujagyslių ligų rizika

 

Daugybė mokslinių tyrimų ir metaanalizių baltojo chalato hipertenziją susiejo su padidėjusia širdies ir kraujagyslių ligų ir jų komplikacijų rizika. Vis dėlto pirmieji moksliniai tyrimai, kuriais siekta nustatyti baltojo chalato hipertenzijos bei širdies ir kraujagyslių sistemos ligų ryšį, klaidingai parodė, kad sergamumas ir mirštamumas nuo širdies ir kraujagyslių ligų, sergant baltojo chalato hipertenzija, yra panašus į tą, kuris nustatomas ir sveikiems asmenims. Atlikus detalesnius mokslinius tyrimus ir jų rezultatus susisteminus metaanalizėse, paaiškėjo, kad baltojo chalato hipertenzijos nulemta širdies ir kraujagyslių ligų rizika yra tarpinė. Vadinasi, ji gerokai didesnė už tą, kurią patiria sveikas asmuo, tačiau mažesnė nei ta, kurią sukelia nuolat padidėjęs AKS. Prie tokios pat išvados buvo prieita išanalizavus prospektyviojo klinikinio tyrimo IDHOCO (angl. International Database of Home Blood Pressure in Relation to Cardiovascular Outcomes) rezultatus…

Daugiau skaitykite leidinyje „Internistas“ Nr.1, 2018.

Parengta pagal Grassi G. White-coat hypertension: not so innocent. E-Journal of Cardiology Practice. Oct. 2016;Vol. 14:Nr. 26–21.

 

Gyd. Justas Simonavičius

Vilniaus universiteto ligoninės Santaros klinikos


138 mintys apie “Baltojo chalato hipertenzija – dažna, bet per menkai įvertinta būklė

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