Clinical syndromes in arterial hypertension. Arterial hypertension: what is it? High blood pressure syndromes

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

Hypertension is rapidly "getting younger", today it is not only a disease of the elderly, but is often found in pregnant women, and is becoming increasingly common among adolescents.

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

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

The optimal blood pressure values ​​are 120-130 by 80-89 mm Hg. if they are higher, then it is necessary to start actively treating hypertension. However, very few people diagnose this disease at an 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 control their pressure.

The sooner arterial hypertension is detected and started to keep it under control, the less in the future the risk of developing complications of hypertension (coronary artery disease, atherosclerosis, kidney disease, a decrease in testosterone levels in the blood, erectile dysfunction).

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

Its useful to note

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

What is the danger of hypertension

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

• Hypertensive crisis- the most common exacerbation of arterial hypertension, can occur both with a relatively satisfactory condition of the patient, and be caused by the psychophysical stress of the patient. Developing at a high rate, a hypertensive crisis sharply raises blood pressure, causes severe headache, dizziness, tachycardia or arrhythmia, nausea and vomiting. At risk are those who suffer from meteorological dependence, are in the pre-climatic period.
• Myocardial infarction- complicated by hypertension can proceed for several minutes and be fatal. The main symptom is a prolonged pain attack.
• Stroke- impaired blood circulation in the vessels of the brain, cerebral hemorrhage, characterized by a sudden severe headache, which is quickly joined by other symptoms from the brain: speech impairment, crooked mouth, paralysis of one part of the body. If you take urgent measures and make capillary bloodletting for hypertension. then this process can be reversible.
• Angina pectoris- the disease is less transient. Violation of the heart is caused by strong emotional overload, fatigue. Is accompanied by severe dull pain in the chest area, feeling bad, 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 the total weakness of the patient, in which he is not able to endure elementary physical activity: independent lifting, walking, etc.
• Ischemic disease hearts- insufficient blood supply to the coronary arteries, as a result of which there is an insufficient nutrition of the heart. With careful adherence to the prescribed treatment of hypertension, it is not difficult to avoid the development of coronary artery disease.
• Renal failure- impaired renal function, destruction of neurons, partial inability to remove toxins from the body. Arterial hypertension is the second, after diabetes mellitus. the cause of the development in a person of acute or chronic form renal failure.
• Distorted vision- occurs as a result of a violation of the blood supply to the retina and optic nerve... A sharp increase in blood pressure can cause spasm of the artery that feeds the optic nerve, damage the integrity of the retinal vessels. Hypertension is dangerous by such pathologies as hemorrhage in the retina or vitreous body: 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, which are so dangerous for hypertension, it is necessary to consult a doctor in a timely manner and carry out an examination, which will help determine the stage of development of the disease and prescribe the required treatment.

The degree of hypertension: classification, forms

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

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

The primary task in the diagnosis of 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 treatment of 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 intake of some medicines, with neuroses, excessive use of caffeine, other stimulants.

When diagnosing to select correct tactics Treating essential hypertension, doctors usually classify the condition according to the level of blood pressure. In international practice, there are three degrees of hypertension:

• Hypertension 1 degree- systolic pressure 140-159 mm Hg. diastolic pressure 90-99 mm Hg Light form a disease in which an abrupt change in blood pressure is characteristic can either independently return to normal 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 drops.
• Hypertension 3 degrees- systolic above 180 mm Hg. diastolic above 110 mm Hg Severe form, pressure is consistently at the level of pathological indicators, proceeds with severe complications, it is difficult to correct with medications.

Separately isolated systolic hypertension 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, ischemic 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.

Useful information

It is worth noting another insignificant group - the so-called "white coat hypertension", when, under the influence of psycho-emotional factors, a person's blood pressure rises only when it is measured by a medical professional. In such cases, the diagnosis is clarified by repeated blood pressure measurements in a calm home environment.

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

• Transistor ( initial stage) hypertension... The increase in pressure is periodic, returning to normal values; drugs that reduce blood pressure are not used.
• Labile hypertension... An increase in blood pressure is directly related to a provoking factor: stress, severe psychological or physical stress. To stabilize the pressure, medication is needed.
• Stable arterial hypertension... A persistent increase in pressure, in which serious supportive therapy is used.
• Malignant form... Increasing pressure to very high levels, the disease progresses rapidly and leads to the development of serious complications.
• Crisis form... Periodic hypertensive crises are characteristic against the background of normal or slightly increased blood pressure.

Assessment of the severity of hypertension and risk possible complications is possible only on the basis of a thorough examination: general and biochemical analyzes, Ultrasound of the heart and other organs, ECG, examination of the fundus. A complete examination of a patient with arterial hypertension is usually carried out during inpatient treatment.

High blood pressure is the main alarming symptom of hypertension in both men and women

Symptoms of hypertension may be absent for a long time, and if a person does not constantly use a tonometer, 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, because in a number of situations (stress, fear or anger) pressure can increase, and then independently return to normal. However, few control their blood pressure, so you should pay attention to the following symptoms, indicating the development of arterial hypertension:

• Headache. Most often it manifests itself in the occipital, parietal region or in the temples. It can occur both at night and immediately after waking up. As a rule, it is aggravated by mental or physical activity... Sometimes it is accompanied by swelling of the eyelids and face.
• Dizziness. Sometimes even with a little physical effort: coughing, turning or tilting the head, a sharp rise.
• Pain in the region of the heart. They arise not only during emotional stress, but also at rest. Both prolonged aching, squeezing pains and short-term, stabbing pains are possible. Do not disappear after taking nitroglycerin.
• Strong heartbeat.
• Noise in ears.
• Visual impairment: veil, fog, "flies" before the eyes.
• Arterial involvement: cold limbs, intermittent claudication.
• Swelling of the legs. Indicate impaired renal excretory function or heart failure.
• Dyspnea. It occurs both during physical exertion and at rest.

It's important to know

A hypertensive crisis is an emergency caused by an excessively high level of blood pressure; it can also be classified as symptoms of grade 2 and 3 hypertension. At the same time, patients with grade 1 arterial hypertension, strictly following the doctor's recommendations and following a diet for hypertensive patients, can achieve complete disappearance of the unpleasant symptoms of the disease.

This is not to say that the symptoms of hypertension in men and women differ significantly, but in fact, men are really more susceptible to this disease, especially when it comes to age group from 40 to 55 years old. This is partly due to the difference in physiological structure: men, unlike women, have a greater body weight, respectively, and 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, correct lifestyle. The number of stressful situations at work, alcohol consumption and smoked cigarettes is greater in men, but this no longer refers to the symptoms of hypertension, but to the reasons for its development.

Treatment of hypertension with medication and folk remedies

Treatment of hypertension, as well as other diseases that are difficult to diagnose and require constant therapy ( diabetes, allergy, prostatitis and impotence), should be drawn up and prescribed only by a specialist. If restrictions on food, use table salt, quitting alcohol and smoking, avoiding stress and other corrected causes of hypertension does not help to normalize the level of blood pressure, pills from high pressure.

Methods for treating hypertension

In the treatment of hypertension folk remedies side effects are usually absent. You do not have to run to the pharmacy for expensive drugs and stand in line for the doctor to write 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; in the development of the disease, an important role is played by both internal systems organism, and external factors. If, in symptomatic hypertension, the causes of an increase in blood pressure are caused by other diseases, then in essential hypertension, and this form is recorded in 85% of cases, it is not possible to establish the exact reasons for high blood pressure, it arises on its own.

There are many risk factors that contribute to a persistent increase in blood pressure, it is these factors that are considered to be the causes of hypertension. These include:

• Age, men over 55 years old, women over 65 years old. With age, the walls of blood vessels lose elasticity, which increases their resistance to blood flow, as a result, the pressure rises.
• Hereditary predisposition.
• Floor. As already mentioned, men are more likely to suffer from arterial hypertension.
• Violation of fat metabolism, obesity (men with a waist volume of more than 102 cm, women - more than 88 cm).
• Diabetes.
• Smoking. It 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 quits drinking is reduced by at least fifteen points.
• Excessive salt intake. Excessive intake of sodium, the main constituent of table salt, is one of the most significant reasons for an increase in 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, on average, a person consumes three times the amount of salt that he needs, learn not to add salt to food.
• Insufficient physical activity, sedentary lifestyle.
• Exposure to stress.
• Violation of cholesterol metabolism.
• Insufficient intake of potassium with food.
• Increased level of adrenaline in the blood.
• Congenital heart defects.

Various kidney diseases, late toxicosis of pregnant women, regular intake 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 on their own or with the help of doctors: to treat obesity, reduce blood cholesterol levels, the number of cigarettes smoked, alcohol or salt consumed, lose weight, and so on.
• There is no way to avoid: age and hereditary predisposition.

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

Complaints: headache, more often in the occipital and parietal regions, heaviness in the back of the head, dizziness, noise in the head, "flying flies" before the eyes, stabbing or aching pains in the precordial region.

Examination and palpation: often hypersthenic constitution, increased nutrition, facial flushing. The apical impulse is diffuse, resistant, displaced to the left, sometimes downward. The pulse is firm, full.

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

Auscultation: I tone at the apex is weakened, accent of tone II above the aorta. As the changes from the left ventricle increase, a functional systolic murmur at the apex of the heart, heart rhythm disturbances may appear.

Instrumental research methods

X-ray: Signs of left ventricular hypertrophy, aortic configuration of the heart, the aorta is enlarged, 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 can be flattened, smoothed or even negative T in I, aVL, V 5-6.

Ocular fundus: retinal arteries are narrowed, twisted, veins are dilated. Symptoms of Guna-Salus I, II, III Art. 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 the level of blood pressure, is not associated with any independent damage to organs and systems. 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 currently not used.

Etiology and pathogenesis

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

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 into the body);

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

traumatic brain injury;

intoxication (smoking, alcohol);

violation of fat metabolism (obesity);

hypodynamia.

The factors determining the prognosis in hypertension (risk stratification criteria) are outlined below.

In the occurrence of EAH, a very large role is played by burdened by heredity ... It is believed that the genetic defect is associated with a defect in plasma membranes and is expressed in impaired transport of monovalent cations and calcium. However, in order for the disease to occur, it is necessary to have predisposing factors (stress, smoking, physical inactivity, etc.) 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 the disruption of normal neurogenic and / or humoral regulation of 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 links in the pathogenesis of hypertension are:

1. Strengthening of 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). The greatest importance is attached to this link.

2. Depletion of depressive factors:

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

decrease in the production of sodium uretic atrial factor (PNUF);

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

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

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

This is the main pathological condition organism that creates everything the necessary conditions for the development of disorders in the work 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 total value with the term widely used abroad, "essential hypertension" and means an increase in the level of blood pressure above normal for no apparent reason.

Symptoms of pathology

Signs of high blood pressure are often not 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 of arterial hypertension:

GARDEN within normal limits for healthy person should be at the level of 120-129 mm Hg, and normal DBP - 80-84 mm Hg. A systolic pressure of 130 to 139 mm Hg is called highly normal, and a diastolic pressure is 85 to 89 mm Hg. Art.

ICD-10 coding

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 the 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 degree of CVD:

1. The male sex is more prone to the occurrence of disorders of the heart and blood vessels at the age of over 55;
2. Cases of arterial hypertension are more common over the age of 65;
3. Smoking helps to reduce the tone of the vascular walls and increase blood pressure on them;
4. Violations of the lipid composition of the blood (an increase in the number of low-density lipoproteins and a decrease in the amount of high-density lipoproteins);
5. Increased blood glucose;
6. Obese people almost always have hypertension;
7. Poor family history of heart and vascular disease.

To determine the CCP, 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 EchoS and ECG;
3. The presence of chronic kidney disease and concomitant microalbuminuria;
4. The formation of atherosclerotic plaques on the walls of the carotid arteries;
5. Diabetes;
6. Vascular pathology of the brain;
7. Cardiac ischemia;
8. Pathological changes in the retina.

Blood pressure measurement technique

How to measure blood pressure correctly? Various devices are used to measure blood pressure in the arterial bed. The doctor measures the pressure either nurse... The patient can also take measurements on their own using an automatic blood pressure monitor.

The patient should be in a sitting position, with an arm raised to the level of the heart, in a relaxed state. A few minutes before the measurement, the intake of coffee or tea, sympathomimetics, physical activity is excluded.

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

With the help of a special rubber bulb, air is injected until the pulse on the radial artery is no longer registered. Then air slowly descends. Using a phonendoscope, you need to register Korotkov's tones. When the first tone is heard, the SBP is recorded, and when the last - the DBP level. The measurement is carried out twice. In the future, the pressure is determined on the hand on which the most was recorded.

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

ABPM is a 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 during the day. The device constantly registers changes in blood pressure arterial blood in line. To the patient, recording his actions and the time of taking certain medications during monitoring.

Indications for performing ABPM and SCAD:

1. Suspicions that the pressure rises at the sight of 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 in its values ​​after several visits to the doctor;
4. With a decrease in blood pressure during the change from horizontal to vertical (standing);
5. With a significant drop in blood pressure during sleep in the daytime;
6. If hypertension is suspected, nocturnal.

By using the sphygmogram and shoulder pressure measurements, central BP can be calculated. To begin with, a collection of complaints and anamnesis of life, disease is carried out. Then the height and body weight are measured in order to calculate the patient's body mass index.

Diagnosis of pathology

1. Normalization of nutrition. Increasing the amount of food vegetable 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 activity). It is advisable not to engage in power sports;
5. Weight loss 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 drugs for pressure:

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

   Preparations of this series protect the vascular wall from the imposition of thrombotic masses, prevent the onset 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, metabolic disorders in the body may occur. Most often they are combined with an ACE inhibitor or BAP. Aldosterone receptor antagonists (spironolactone) lower 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, heart failure. 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, prevent the occurrence of strokes.

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

There are other classes of antihypertensive drugs:

1. Imidazoline receptor agonists (rilmenidine, moxonidine). They have a positive effect on the body's carbohydrate metabolism, contribute to the patient's weight loss;
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 have the expected effect. There are such rational combinations of drugs: a diuretic and an ACE inhibitor, a diuretic and an ARB, an ACE inhibitor and calcium antagonists, a diuretic and calcium antagonists, ARBs 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 different doses. Aspirin also prevents the formation of atherosclerotic plaques on the walls of blood vessels.

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

Hypertensive crisis treatment

A hypertensive crisis is a sudden onset of an increase in blood pressure above 160/120 mm Hg, accompanied by certain clinical manifestations. Crises are uncomplicated and 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 lower 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;
• Diuretic drugs;
• Antipsychotics.

Uncomplicated crisis is stopped faster, oral antihypertensive drugs are used (captopril, clonidine, moxonidine, nifedipine, etc.).

Prophylaxis

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

Treatment of arterial hypertension is selected individually for each individual. The patient's daily regime and diet, the nature of the physique and many other factors are taken into account. Acceptance of drugs 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
NEEDS CONSULTATION OF THE ATTENDANT DOCTOR