Clinical syndromes in arterial hypertension. Arterial hypertension: what is it? Syndromes with high blood pressure

Hypertension (arterial hypertension) is the most common disease of the cardiovascular system.

Hypertension is rapidly becoming “younger”; today it is no longer a disease only of older people, but is often found in pregnant women, and is becoming increasingly common in adolescents.

What is arterial hypertension? The answer to this question can be found in the definition of the condition for this disease.

It is characterized by chronically elevated blood pressure, When highest indicator(systolic pressure) exceeds 140 mm Hg. and the lowest (diastolic pressure) is above 90 mm Hg. subject to at least three measurements made in different times in a person who is in a calm state.

Optimal blood pressure readings are 120-130 at 80-89 mmHg. if they are higher, then it is necessary to begin actively treating hypertension. However, few people diagnose this disease on early stage: about 35% of men and 55% of women know about their high blood pressure, treatment arterial hypertension only half of them are engaged, and only 6% of the male population and 20% of the female population control their blood pressure.

The sooner you identify arterial hypertension and begin to keep it under control, the lower the risk of developing complications of hypertension in the future (coronary artery disease, atherosclerosis, kidney disease, decreased testosterone levels in the blood, erectile dysfunction).

Hypertension can be one of the causes of impotence in men.

It is worth noting

The main goal of treating hypertension is to constantly monitor blood pressure in order to avoid even more serious problems with health, since it is impossible to completely cure this disease.

Why is hypertension dangerous?

With prolonged high blood pressure, the walls of blood vessels thicken and lose their ability to relax, this prevents normal blood supply and, as a result, the saturation of tissues and organs with oxygen and other nutrients, reducing their functional activity. Let's take a closer look at why hypertension is dangerous:

• Hypertensive crisis- the most common exacerbation of arterial hypertension, can occur both in the relatively satisfactory condition of the patient, and can be caused by the psychophysical stress of the patient. Developing at high speed, a hypertensive crisis sharply increases blood pressure, causing severe headache, dizziness, tachycardia or arrhythmia, nausea and vomiting. Those at risk are those who suffer from weather dependence and are in the preclimatic period.
• Myocardial infarction- complicated by hypertension can occur within a few minutes and lead to fatal outcome. The main symptom is a prolonged pain attack.
• Stroke- disturbance of blood circulation in the vessels of the brain, hemorrhage in the brain, characterized by a sudden severe headache, which is quickly accompanied by other symptoms from the brain: speech impairment, twisted mouth, paralysis of one part of the body. If you take urgent measures and do capillary bloodletting for hypertension. then this process can be reversible.
• Angina pectoris- the disease is less transient. Disturbances in the functioning of the heart cause severe emotional overload and fatigue. Accompanied by severe dull pain in the chest area, feeling unwell, may cause frequent vomiting.
• Heart failure- a chronic condition of the heart muscle in which it is unable to provide oxygen to the organs and tissues of the body. It is characterized by total weakness of the patient, in which he is unable to endure basic physical activity: getting up on his own, walking, etc.
• Ischemic disease hearts- insufficient blood supply to the coronary arteries, resulting in insufficient nutrition of the heart. If you carefully follow the prescribed treatment for hypertension, it is not difficult to avoid the development of coronary artery disease.
• Kidney failure- impaired kidney function, destruction of neurons, partial inability to remove toxins from the body. Arterial hypertension is second only to diabetes mellitus. cause of a person developing acute or chronic form renal failure.
• Distortion of vision- occurs as a result of disruption of the blood supply to the retina and optic nerve. A sharp increase in blood pressure can cause spasm of the artery supplying the optic nerve and damage the integrity of the retinal vessels. Hypertension is dangerous due to pathologies such as retinal hemorrhage or vitreous: the first leads to the formation of a black spot in the field of vision, the second leads to loss of vision in the affected eye.

To avoid any complications that are so dangerous with hypertension, it is necessary to consult a doctor in a timely manner and undergo an examination, which will help determine the stage of development of the disease and prescribe the required treatment.

Degrees of hypertension: classification, forms

Based on the nature of the assessment of one or more criteria, a number of classifications of hypertension are used.

There are stages of development such as origin, form of course, blood pressure level, degree of damage to target organs.

The primary task when diagnosing arterial hypertension is to differentiate the nature of the disease. There are two large groups here:

• primary or essential hypertension - increased blood pressure is the root cause;
• secondary or symptomatic arterial hypertension - high blood pressure is caused by diseases of other organs or systems: kidneys, heart, glands internal secretion, lungs, thyroid gland.

According to experts

Treatment of symptomatic hypertension cannot occur without treating the disease that caused it, and begins with it. In some cases, along with the elimination of the underlying disease, hypertension also disappears.

Also, blood pressure, up to a hypertensive crisis, may increase due to improper use of certain medicines, with neuroses, excessive consumption of caffeine and other stimulants.

When diagnosing to choose correct tactics When treating essential hypertension, doctors usually classify the disease according to blood pressure levels. In international practice, there are three degrees of hypertension:

• Hypertension 1st degree- systolic pressure 140−159 mm Hg. diastolic pressure 90−99 mm Hg. Light form A disease characterized by sudden changes in blood pressure can either return to normal on its own or rise again.
• Hypertension 2 degrees- systolic 160−179 mm Hg. diastolic 100−109 mm Hg. Moderate form, the increase in pressure is more prolonged, up to normal values rarely falls.
• Hypertension 3 degrees- systolic above 180 mm Hg. diastolic above 110 mm Hg. Severe form, pressure is consistently at the level of pathological indicators, occurs with severe complications, and is difficult to correct with medications.

Separately, isolated systolic hypertension is distinguished; it occurs in about a third of elderly people with arterial hypertension. This form is caused by age-related loss of elasticity of large vessels, often accompanied by myocardial infarction, coronary heart disease, congestive heart failure and left ventricular hypertrophy. Blood pressure indicators: systolic up to 160 mm Hg. and above, diastolic - below 90 mm Hg.

Helpful information

It is worth noting another minor group - the so-called “white coat hypertension”, when, under the influence of psycho-emotional factors, a person’s blood pressure increases only at the time it is measured by a medical professional. In such cases, the diagnosis is clarified by repeated pressure measurements in a quiet home environment.

In addition to the degree of hypertension, when making a diagnosis, risk factors that can lead to complications of the cardiovascular system and stage are also assessed. clinical course diseases:

• Transistor ( initial stage) hypertension. The increase in pressure is periodic, returning to normal values; Blood pressure lowering drugs are not used.
• Labile hypertension. An increase in blood pressure is directly related to the provoking factor: stress, severe psychological or physical stress. To stabilize the pressure, drug treatment is necessary.
• Stable arterial hypertension. Persistent increase in blood pressure, which requires serious supportive therapy.
• Malignant form. Increasing blood pressure to very high levels, the disease quickly progresses and leads to the development of serious complications.
• Crisis form. Characterized by periodic hypertensive crises against a background of normal or slightly elevated blood pressure.

Assessment of hypertension severity and risk possible complications is possible only on the basis of a thorough examination: general and biochemical tests, Ultrasound of the heart and other organs, ECG, fundus examination. Full examination A patient with arterial hypertension is usually treated as an inpatient.

High blood pressure is the main warning sign of hypertension in both men and women

Symptoms of hypertension may be absent for quite a long time, and if a person does not constantly use a blood pressure monitor, he can find out about his disease, having already begun to treat its complications.

Often hypertension has no manifestations at all, except for its main symptom - persistent high blood pressure.

Moreover, the concept of “persistent” or “chronic” is key here, since in a number of situations (stress, fear or anger) pressure can increase and then return to normal on its own. However, few people control their blood pressure levels, so you should pay attention to the following symptoms indicating the development of arterial hypertension:

• Headache. Most often it appears in the occipital, parietal region or temples. It can occur both at night and immediately after waking up. As a rule, it intensifies with mental or physical activity. Sometimes accompanied by swelling of the eyelids and face.
• Dizziness. Sometimes even with little physical effort: coughing, turning or tilting the head, or sudden rise.
• Pain in the heart area. They occur not only during emotional stress, but also at rest. Both long-term aching, squeezing pain and short-term, stabbing pain are possible. They do not disappear after taking nitroglycerin.
• Palpitations.
• Noise in ears.
• Visual impairment: blurred vision, fog, spots before the eyes.
• Arterial damage: cold extremities, intermittent claudication.
• Swelling of the legs. Indicate a violation of the excretory function of the kidneys or heart failure.
• Dyspnea. Occurs both during physical activity and at rest.

It is important to know

Hypertensive crisis - emergency, caused by excessively high blood pressure, can also be considered symptoms of stage 2 and 3 hypertension. At the same time, patients with arterial hypertension of the 1st degree, strictly following the doctor’s recommendations and following a diet for hypertensive patients, can achieve complete disappearance of the unpleasant symptoms of the disease.

It cannot be said that the symptoms of hypertension in men and women are significantly different, but in fact, men are indeed more susceptible to this disease, especially age group from 40 to 55 years. This is partly due to the difference physiological structure: men, unlike women, have greater body weight, and accordingly, the volume of blood circulating in their vessels is significantly higher, which creates favorable conditions for high blood pressure.

On the other hand, women are more responsible for their health, the right image life. The number of stressful situations at work, alcohol consumed and cigarettes smoked is higher in men, but this no longer refers to the symptoms of hypertension, but to the reasons for its development.

Treatment of hypertension with medications and folk remedies

Treatment of hypertension, as well as other diseases that are difficult to diagnose and require constant therapy ( diabetes, allergies, prostatitis and impotence), should be compiled and prescribed only by a specialist. If restrictions on food, consumption table salt, giving up alcohol and smoking, avoiding stress and other correctable causes of hypertension does not help normalize blood pressure levels, pills will be prescribed for high pressure.

Methods for treating hypertension

In the treatment of hypertension folk remedies side effects, as a rule, are absent. You don’t have to run to the pharmacy for expensive medications and stand in line for the doctor to write out another prescription. All you need to do is take some time for yourself, change your diet and learn how to manage stress.

Causes of high blood pressure and the development of hypertension

The causes of arterial hypertension are still not completely clear; both internal systems body and external factors. If with symptomatic hypertension the causes of increased blood pressure are caused by other diseases, then with essential hypertension, and this form is registered in 85% of cases, the exact causes of high blood pressure cannot be established; it arises independently.

There are many risk factors that contribute to persistent high blood pressure bloodstream, they are usually considered to be the causes of hypertension. These include:

• Age, for men over 55 years, for women over 65 years. With age, the walls of blood vessels lose their elasticity, which increases their resistance to blood flow, and as a result, the pressure increases.
• Hereditary predisposition.
• Floor. As already mentioned, men are more likely to suffer from arterial hypertension.
• Impaired fat metabolism, obesity (men with a waist size of more than 102 cm, women with a waist size of more than 88 cm).
• Diabetes.
• Smoking. Causes an immediate rise in blood pressure, and smokers with many years of experience are susceptible to vascular diseases.
• Alcohol abuse. The blood pressure of a person who stops drinking drops by at least fifteen points.
• Excessive salt intake. Excessive intake of sodium, the main component of table salt, into the body is one of the most significant causes of increased blood pressure in hypertensive patients: sodium chloride prevents the removal of fluid from the body, which increases the already high vascular tone of the patient. Remember, the average person consumes three times the amount of salt that he needs, learn not to add salt to your food.
• Insufficient physical activity, sedentary lifestyle.
• Exposure to stress.
• Cholesterol metabolism disorder.
• Insufficient intake of potassium from food.
• Increased level of adrenaline in the blood.
• Congenital heart defects.

Various kidney diseases, late toxicosis of pregnant women, regular use of certain medications, in some cases this also applies to oral contraceptives, should be attributed to the causes of secondary hypertension.

The above risk factors can be divided into two large groups :

• Which can be eliminated independently or with the help of doctors: treat obesity, reduce blood cholesterol levels, the number of cigarettes smoked, alcohol or salt consumed, lose excess weight and so on.
• Which cannot be avoided: age and hereditary predisposition.

Therefore, those who are in the so-called second risk group need to especially carefully monitor their health and monitor and prevent arterial hypertension. And everyone who has at least one of the above factors should constantly monitor their blood pressure levels and, of course, lead a normal and active lifestyle.

Complaints: headache, often in the occipital and parietal regions, heaviness in the back of the head, dizziness, noise in the head, “flying spots” before the eyes, stabbing or aching pain in the precordial region.

Inspection and palpation: often hypersthenic constitution, increased nutrition, facial hyperemia. The apex beat is diffuse, resistant, shifted to the left, sometimes downward. The pulse is hard and full.

Percussion: the left border of relative cardiac dullness is shifted to the left in the IV-V intercostal spaces due to the enlargement of the left ventricle. In later stages - expansion of boundaries vascular bundle(in the 2nd intercostal space).

Auscultation: The first tone at the apex is weakened, the accent of the second tone is over the aorta. As changes in the left ventricle increase, functional systolic murmur may appear at the apex of the heart and cardiac arrhythmias.

Instrumental research methods

X-ray: Signs of left ventricular hypertrophy, aortic configuration of the heart, the aorta is dilated and thickened.

ECG: Levogram: R I >R II >R III, S III >S I, RV 5 - 6 >RV 4. Signs of left ventricular overload: S-T segment in I, aVL, V 5-6 below the isoline. There may be flattened, smoothed or even negative T in I, aVL, V 5-6.

Ocular fundus: retinal arteries are narrowed, tortuous, veins are dilated. Symptoms of Guna-Salus I, II, III degrees. Symptoms of "copper" and "silver" wire.

Ultrasound of the heart: thickening of the wall of the left ventricle.

Essential arterial hypertension

This disease, characterized by an increase in blood pressure, is not associated with any independent damage to organs and systems. It occurs, according to various authors, in 15-30% of the entire adult population. Among all arterial hypertension, essential arterial hypertension (EAH) accounts for 90-95% of cases. A synonym for EAH is “hypertension.” However, according to the recommendations of WHO experts, the term “hypertension” is not currently used.

Etiology and pathogenesis

The reasons for the development of EAH are still unclear. We can only say with confidence that this is a multifactorial disease and among predisposing factors highlight:

neuropsychic trauma, frequent emotional stress;

hereditary constitutional features;

occupational hazards (noise, constant eye strain, heavy physical activity);

dietary habits (excessive consumption of table salt, deficiency of calcium, magnesium, excessive intake of cadmium);

age-related restructuring of the diencephalic-hypothalamic structures of the brain (during menopause);

traumatic brain injuries;

intoxication (smoking, alcohol);

violation of fat metabolism (obesity);

physical inactivity.

Factors that determine the prognosis for hypertension (risk stratification criteria) are outlined below.

A very important role is played in the occurrence of EAH burdened heredity . It is believed that the genetic defect is associated with a defect in plasma membranes and is expressed in a violation of the transport of monovalent cations and calcium. However, for the disease to occur, the presence of predisposing factors (stress, smoking, physical inactivity, etc.) is necessary. According to modern concepts, the pathogenesis of hypertension is a complex complex of metabolic, neurohumoral, structural, hemodynamic disorders leading to the development of the disease. The disease is based on a disruption of normal neurogenic and/or humoral regulation vascular tone with the gradual formation of organic changes in the heart and vascular bed, the development of ischemia of various organs and systems and their functional failure.

The most studied parts of the pathogenesis of hypertension are:

1. Strengthening pressor factors:

activation of the sympathoadrenal system (SAS);

increased production of various neuropetic hormones (adrenaline, norepinephrine, vasopressin, prolactin, serotonin, etc.);

activation of the renin-angiotensin-aldosterone system (RAAS). This link is given the greatest importance.

2. Depletion of depressor factors:

decrease in the level of prostaglandins, activity of the kinin-kallikrein system;

decreased production of atrial natriuretic factor (NAUF);

decrease in the production of endothelial relaxing factor - nitric oxide (NO).

Metabolic mechanism of hypertension development (development of metabolic syndrome). With this syndrome there is a combination of obesity, diabetes mellitus, and hyperlipidemia. In this case, hyperinsulinemia develops with simultaneous insulin resistance. Hypertension against the background of metabolic syndrome is particularly persistent, malignant, and resistant to treatment.

What is arterial hypertension? The concept means a persistent increase in blood pressure during cardiac systole (SBP) above 140 mm Hg. Art. and during diastole (DBP) more than 90 mm Hg.

This is the main thing pathological condition organism that creates everything the necessary conditions for the development of disturbances in the functioning of the heart muscle and neurocirculatory dysfunctions.

The term “Hypertension” was first introduced by the Soviet academician F.G. Lang. The significance of this diagnosis is general meaning with the term widely used abroad, “essential hypertension” and means an increase in blood pressure levels above normal without any obvious reason.

Symptoms of pathology

Signs of high blood pressure often cannot be recorded, which makes the disease hidden threat. Persistent hypertension is manifested by headaches, fatigue, compression in the back of the head and temples, nosebleeds, and nausea.

Classification arterial hypertension:

SBP is within normal limits for healthy person should be at the level of 120-129 mmHg, and normal DBP should be 80-84 mmHg. Systolic pressure from 130 to 139 mmHg is called high normal, and diastolic pressure is from 85 to 89 mmHg. Art.

Coding according to ICD-10

Diseases characterized by high blood pressure I10-I15

There is a scale for assessing cardiovascular risk (CVR), which affects the further course and development of the disease. To determine CVR, it is important to take into account not only the level of blood pressure, but also concomitant dysfunctions of other organs. Thus, the risk is low, medium, high and very high.

Complications after arterial hypertension

Causes and risk factors

Risk factors for arterial hypertension, which I take into account when making a diagnosis and the degree of cardiovascular risk:

1. Males are more prone to developing disorders of the heart and blood vessels at the age of over 55 years;
2. Cases of arterial hypertension are more common in people over 65 years of age;
3. Smoking helps to reduce the tone of the vascular walls and increase blood pressure on them;
4. Blood lipid disorders (increased number of low-density lipoproteins and decreased number of high-density lipoproteins);
5. Increased blood glucose levels;
6. Obese people almost always suffer from hypertension;
7. Unfavorable family history of heart and vascular diseases.

To determine the SSR, the following factors are taken into account:

1. Increased pulse pressure;
2. Signs of hypertrophy of the left chambers of the heart, in particular the ventricle, on EchoCS and ECG;
3. Availability chronic illness kidneys and concomitant microalbuminuria;
4. Formation of atherosclerotic plaques on the walls of the carotid arteries;
5. Diabetes;
6. Pathology of cerebral vessels;
7. Cardiac ischemia;
8. Pathological changes in the retina of the eye.

Blood pressure measurement technique

How to measure blood pressure correctly? To measure blood pressure levels in the arterial bed, various devices. The doctor measures your blood pressure or nurse. The patient can also take the measurement independently using an automatic tonometer.

The patient should be in a sitting position, with his arm raised to the level of his heart, in a relaxed state. Avoid taking coffee or tea, sympathomimetics, or physical activity a few minutes before measurement.

A special cuff is placed on the arm so that its lower edge is 2 cm higher elbow joint. Cuffs come in different sizes! Obese people need to measure their blood pressure only with a 20*42cm cuff. or 16*38cm.

Using a special rubber bulb, air is pumped until the pulse on the radial artery ceases to be recorded. Then the air slowly descends. Using a phonendoscope, you need to register Korotkoff sounds. When the first tone is heard, the SBP is recorded, and when the last tone is heard, the DBP level is recorded. The measurement is carried out twice. Subsequently, the pressure is determined on the arm on which the highest was recorded.

Self-monitoring of blood pressure is actively used, which helps to establish dynamic changes in pressure levels. ABPM is often recommended in combination with it.

ABPM is 24-hour monitoring of a patient's blood pressure.

For this method, a special portable device with a cuff is used, which the patient carries with him throughout the day. The device constantly records changes in blood pressure arterial blood in line. The patient records his actions and the time of taking certain medications during monitoring.

Indications for ABPM and SCAD:

1. Suspicions that blood pressure rises when you see a doctor (psychological factor);
2. The presence of damage to the heart, kidneys or other organs without a clear increase in blood pressure;
3. If blood pressure fluctuates during several visits to the doctor;
4. When blood pressure decreases during a change from a horizontal to a vertical position (standing);
5. With a significant drop in blood pressure during sleep in the daytime;
6. If nocturnal hypertension is suspected.

By using sphygmogram results and brachial pressure measurements, central BP levels can be calculated. To begin with, complaints and anamnesis of life and illness are collected. Height and weight are then measured to calculate the patient's body mass index.

Diagnosis of pathology

1. Normalization of nutrition. Increasing the amount of food plant origin, reducing the amount of salt intake to 5 g per day, limiting the intake of fatty foods;
2. Exclusion of alcoholic beverages;
3. It is recommended to give up cigarettes. Smoking adversely affects cardiovascular system;
4. Dosed physical activity (30 minutes every other day, aerobic exercise). It is advisable not to engage in strength sports;
5. Losing weight in case of obesity.

Drug treatment

must be prescribed by a doctor. Self-medication for hypertension is not only ineffective, but can also cause the development of a hypertensive crisis.

Types of blood pressure medications:

1. Angiotensin-converting enzyme inhibitors and drugs that block angiotensin 11 receptors. Drugs in these groups are very often used in the treatment of arterial hypertension. They are especially effective if the patient has hyperfunction of the angiotensin-aldosterone system of the kidneys. Sometimes when using ACE inhibitors, a phenomenon of “escape” effect may occur, as the angiotensin enzyme changes its synthesis pathway. This effect is not observed when taking BAP.
2. Calcium antagonists (CAs) reduce peripheral resistance of the vascular walls, which lowers blood pressure. There are three groups of AKs:
   — Dihydropyridines (Amlodipine, Nifedipine);
   — Phenylalkylamines (Verapamil);
   - Benzothiazepines (diltiazem).

   Drugs of this series protect the vascular wall from the imposition of thrombotic masses, prevent the occurrence of atherosclerosis, and provide a protective function for the kidneys and brain.

3. Thiazide diuretics (hydrochlorothiazide) increase the excretion of chlorine and sodium in the urine, reduce the volume of circulating blood, thereby lowering blood pressure. However, when using such drugs in high doses, disturbances in the metabolic process in the body may occur. Most often they are combined with ACEI or BAP. Aldosterone receptor antagonists (spironolactone) reduce blood pressure by binding to aldosterone receptors. This drug reduces the excretion of potassium and magnesium in the urine.
4. Beta-blockers (bisoprolol, nebivolol, carvedilol). Prescribed if the patient has suffered a myocardial infarction or cardiac dysfunction. The effect is to reduce the frequency and strength of contractions of the heart muscle. However, beta blockers negatively affect the body's metabolism. They prevent the development of cerebral vascular pathology and prevent the occurrence of strokes.

The patient can take as 1 prescribed medicinal product, and carry out combined treatment (2-3 drugs).

There are other classes of drugs against hypertension:

1. Imidazoline receptor agonists (rilmenidine, moxonidine). They have a positive effect on the body’s carbohydrate metabolism and help the patient lose weight;
2. Alpha blockers (prazosin). They also have a positive effect on metabolic processes in the body. Used in combination with other antihypertensive drugs.
3. Renin inhibitors (direct). The drug Aliskiren is used, which reduces the amount of renin in the blood and angiotensin.

Combinations of antihypertensive drugs are used; they must have similar pharmacokinetic properties and produce the expected effect. There are such rational combinations of drugs: diuretic and ACEI, diuretic and ARB, ACEI and calcium antagonists, diuretic and calcium antagonists, ARB and calcium antagonists and others, at the discretion of the attending physician.

If the patient has suffered a myocardial infarction or stroke, it is recommended to take aspirin in various doses. Aspirin also prevents the formation of atherosclerotic plaques on the walls of blood vessels.

If, according to laboratory data, the patient has changes in the lipid profile, statins are prescribed.

Treatment of hypertensive crisis

A hypertensive crisis is a sudden occurrence of an increase in blood pressure above 160/120 mmHg, accompanied by certain clinical manifestations. Crises can be uncomplicated or complicated (there is a threat to the patient’s life).

Treatment of a complicated crisis is carried out in a therapeutic or cardiological inpatient department. It is necessary to reduce blood pressure by 25%, but not in all cases.

The following drugs are used:

• Vasodilators (nitroglycerin, sodium nitroprusside, enalaprilat);
• Beta blockers (metoprolol);
• Ganglion-blocking substances;
• Diuretics;
• Neuroleptics.

An uncomplicated crisis is stopped more quickly; oral antihypertensive drugs are used (captopril, clonidine, moxonidine, nifedipine, etc.).

Prevention

During the period of exacerbation of the disease, it is important to exclude salty and spicy foods and alcohol from the diet. Spend more time relaxing, avoiding heavy mental and physical stress.

Treatment of arterial hypertension is selected for each individual. The patient’s daily routine and diet, body type and many other factors are taken into account. The medication intake is prescribed in detail and explained by the attending physician. It is extremely important that the patient understands the importance of treatment and follows all the doctor’s recommendations.

THERE ARE CONTRAINDICATIONS
CONSULTATION WITH YOUR DOCTOR IS REQUIRED