Bradycardia. Causes, symptoms, signs, diagnosis and treatment of pathology. VSD (Vegetative-vascular dystonia): treatment and symptoms

Vegetative-vascular dystonia (VSD) is a very common disease, which can masquerade as many others, or may have minor clinical manifestations. According to statistics, about 80% of people have some symptoms of VSD. One third of these people require medical care.

What is the autonomic nervous system?

The autonomic nervous system (ANS) consists of two subsystems - sympathetic and parasympathetic, the joint and coordinated activity of which allows, on the one hand, to maintain the internal constancy of the body (homeostasis), and on the other hand, to adapt to changing environmental conditions. The ANS directs autonomous (consciously uncontrolled) regulatory mechanisms, such as:

vascular tone (blood pressure);
heart rate;
secretion of external and internal secretion glands (sweating, salivation, secretion of gastric juice, adrenaline, and so on);
regulation motor activity smooth muscles (intestinal motility, gallbladder, etc.).

Due to various stress factors, chronic lack of sleep, neuroticism and other things, the sympathetic and parasympathetic systems can lose control and begin to work on their own. As a result, a polymorphic clinical picture of vegetative-vascular dystonia appears.

The action of the sympathetic nervous system is realized through the sympatho-adrenal system, the central link of which is catecholamines (adrenaline and norepinephrine). A sharp increase in their concentration (release from the adrenal medulla) leads to sympatho-adrenal crisis (“panic attack”) : tachycardia, rise in blood pressure, fear with subsequent exhaustion of the nervous system.

The parasympathetic nervous system is realized through the parasympathetic nerve fibers, the main representative of which is nervus vagus(nervus vagus). Chemical substance, which is released at the endings of this nerve - acetylcholine, which causes a decrease in blood pressure and heart rate, increases intestinal motility, constricts the pupils, increases sweating and salivation, and increases the activity of the exocrine and internal secretion glands. Excessive activation of the parasympathetic nervous system leads to vagoinsular crisis , which manifests itself as fainting, " bear disease", abdominal pain, the concentration of insulin in the blood increases, which leads to hypoglycemia (decreased concentration of sugar in the blood), which causes excessive sweating.

Depending on which component of the ANS predominates (sympathetic or parasympathetic), there are three main types of this disease:

hypotonic type– the action of the parasympathetic nervous system predominates;
hypertensive type– the action of the sympathetic nervous system predominates;
normotonic type– there is no predominance of one system or another, but there is their dysfunction.

Symptoms of vegetative-vascular dystonia

Symptoms from the cardiovascular system:

increased heart rate (tachyarrhythmia);
decreased heart rate (bradyarrhythmia);
interruptions in the functioning of the heart, palpitations;
pain in the heart area;
increased vascular tone (hypertension);
decreased vascular tone (hypertension);
inability to maintain the proper level of blood pressure when necessary, up to the development of fainting;
due to spasm or vasodilation, both local and general paleness or redness of the skin is possible with a decrease or increase in temperature in this area, respectively.

From the outside respiratory system shortness of breath may occur.

Gastrointestinal symptoms:

diarrhea, constipation;
spasmodic pain;
irritable bowel syndrome.

Symptoms from the central nervous system:

apathy;
hypochondria;
depression;
nervousness;
weather sensitivity;
changes in body temperature;
headache;
insomnia.

Treatment of vegetative-vascular dystonia

Both drug and non-drug methods are used to treat VSD. Moreover, the latter should be given more attention. Among non-drug methods The following treatments can be distinguished.

Maintaining a healthy lifestyle. It all starts with normalizing your daily routine. In the morning you need to get up at 6-7 o'clock and go to bed at 10-11 o'clock. Thus, your sleep time should be about 8 hours. The human body is accustomed to a diurnal lifestyle and if “daytime” hormones are released during the day, then “nighttime” hormones are released at night. For example, the hormone intermedin, which is responsible for preserving youth, is released from the middle lobe of the pituitary gland from 00:00 to 03:00 am and only if the person is sleeping. If he is awake at this time, then intermedin is not released or not released in large quantities. Of course, this has an impact on health. And for the money that you are paid for night hours on duty, in essence, you are selling your youth.

Sleeping conditions should also be optimal. The room where you sleep should be comfortable for you in terms of temperature, humidity, noise level, and so on. Mattresses, pillows, and bed linen should also not cause inconvenience. It is optimal if they are orthopedic. If you suffer from snoring, you should try to eliminate it, as it can cause the so-called Ondine's curse syndrome or sleep apnea. This is a condition when, due to snoring or other reasons, the sleeping person stops breathing. At the same time, he may not even wake up, but his REM sleep phase is replaced by the superficial sleep phase. And if this happens quite often during the night, then the person simply will not get enough sleep.

You cannot engage in monotonous activities for a long time at work. During breaks, you should switch from mental to physical stress, and vice versa. It is advisable to minimize the time spent working at the computer. The same goes for watching TV. You cannot sit in one position for a long time; periodically you should do gymnastics, stretch your joints and muscles, and do eye exercises.

At work (and in life) you need to try to be less nervous. If you are angry with someone and cannot tell them about it, write what you think about them on paper. You don’t have to give this paper to that person. Some of the accumulated aggression can be burned off in the gym. In this matter, you can also use autogenic training, conversations with a psychotherapist, and familiarization with the relevant psychotherapeutic literature.

Quitting alcohol and smoking is mandatory. These habits reduce the body's reserve abilities and often lead to various ailments. Alcohol can help you get through it stressful situation like anesthesia during surgery. But in general, its use has an adverse effect on life and health. Drinking alcohol does not help combat stress problems; it only displaces them and puts them off for later. And then they come back in even larger volumes and, accordingly, more “anesthetic drugs” are required. But, nevertheless, it is recommended to sometimes drink a glass (50 ml) of expensive high-quality vodka or a glass (250 ml) of good wine a day before meals. This will be useful for those for whom the smell, sight and taste of alcohol does not cause a violent chain reaction.

Smoking is no less harmful to the body, as it keeps it in a state of chronic hypoxia and toxemia (intoxication). Of course, this reduces the body's reserve capabilities. In addition, smoking increases the incidence of respiratory system diseases - from colds to cancer.

Physical education class. Morning exercises tone your body for the whole day, especially if it is combined with hardening. It not only wakes you up from sleep, but is also an ideal preventative against many diseases.

In addition to exercise, you should sign up for some sports section. Optimal options at the same time there will be yoga classes, swimming, race walking, hiking and the like. Sports that may create excessive load on the cardiovascular system (bodybuilding, sprinting), as well as in which it is necessary to make sudden movements with a large amplitude and lowering the head below the stomach, due to the possibility of fainting.

Nutrition should be rational and balanced. In addition, to improve the performance nerve impulses and heart function, you should always consume foods high in magnesium and potassium. Food should contain a lot of vitamins and others useful substances. The diet should help normalize body weight. For hypertension, it is better to drink soothing teas, and for hypotension, stimulating teas.

Physiotherapy is also used in the treatment of VSD. These procedures may be as follows:

treatment using laser radiation;
magnetic therapy;
electropheresis with various medications on the neck area;
baths, various showers.

Acupuncture and manual therapy. Depending on the various forms of VSD, the chiropractor selects one or another type of massage.

Spa treatment.

Drug treatment of vegetative-vascular dystonia

Treatment of VSD with the help of drugs produced in case of sharp deterioration states - crises.

So, during sympathoadrenal crisis, caused by an excess of catecholamines, treatment consists of prescribing medications that block the action of adrenaline and norepinephrine - adrenergic blockers(metoprolol, propranolol, atenolol).

Anxiolytics (tranquilizers) have a sedative and anti-anxiety effect. Their administration stops the sympathoadrenal crisis. The main representatives of this group: phenazepam, diazepam.

During vagoinsular crisis, occurring due to excess acetylcholine, a drug is used that blocks its action - atropine. This is a 0.1% solution, which is administered subcutaneously in 1 ml doses. To maintain blood pressure and heart function at the desired level, use a 1% solution cordiamine. It is administered in an amount of 3 ml intramuscularly. For the same purpose, 1 ml of a 10% solution is injected subcutaneously caffeine.

For severe bronchospasm, inhaled bronchodilators are used: atrovent, salbutomol, berotec, berodual. Intramuscular administration of a 5% ephedrine solution in a volume of 1 ml may help.

Lack of glucose in the blood ( hypoglycemia) is eliminated by intravenous administration. You can administer 20 ml of 40% glucose intravenously as a bolus.

Vestibular disorders(dizziness, nausea, vomiting) treated with intramuscular injection of 2 ml of 5% solution haloperidol.

If saved dizziness, then they are treated with cinnarizine And vinpocetine, who take 1 tablet 3 times a day.

Treatment of vegetative-vascular dystonia in children

Treatment of VSD in children is fundamentally the same as in adults. Crises in children are less common, so treatment will consist of normalizing lifestyle, diet, behavior, habits and other things as described above. Drug therapy is carried out in accordance with the age (body weight) of the child. The drugs used are approved in pediatric practice. As a rule, if VSD appeared in childhood, then the risk of VSD disease greatly increases during adult life. Therefore, for such people, prevention of VSD should be considered throughout life.

Vegetative-vascular dystonia - treatment with folk remedies.

Herbal medicine – treatment of vegetative-vascular dystonia with herbs. Great attention should be paid to this treatment. There are many herbs that can both stimulate the body’s activity and calm its excessive activation.

Treatment of hypertensive type VSD

At hypertensive type VSD uses herbs that have a calming, hypnotic effect on the body. These herbs are not an alternative to drug treatment, but only a significant addition to this treatment. They should be taken only if the symptoms of the disease are mild. They are taken for a long time, about 20-30 days. Moreover, they should be taken no more than the specified period to avoid side effects. It is better to use several types of herbs with the same effects, which are used alternately.

Here are the main representatives of herbs with a calming and hypnotic effect: valerian, lemon balm, St. John's wort, motherwort, chamomile, hops, linden, mint, clover, dill, blackberries, strawberries and some others.

Valerian is one of the best herbs in this series, which also has no contraindications. It is best to use valerian tincture, which is taken 15 ml (1 tablespoon) 2 times a day. This treatment lasts one week, then a break is taken for 2 weeks.

Motherwort can significantly lower blood pressure, so it should be used with caution.

Mint and lemon balm are used in the form of teas and tinctures. Long-term use is not recommended, as it may cause Negative influence on the human reproductive system.

Treatment of hypotonic type of VSD

With hypotonic VSD type herbs are used that increase the tone of the body and, in particular, the cardiovascular system. Such herbs include: ginseng, eleutherococcus, coffee, black and green tea.

Ginseng is an adaptogen. Tincture from its root is taken 20 drops 30 minutes before meals. It should be taken in the first half of the day to prevent insomnia. Ginseng not only stimulates the nervous and cardiovascular systems, but also increases potency. Treatment with ginseng should not be continued for too long, otherwise depletion may occur.

Eleutherococcus is also an adaptogen. It selectively stimulates the functioning of the nervous system, improves the transmission of nerve impulses. Take it in the same way as ginseng: in the first half of the day, 30 minutes before meals, 30 drops. The course of treatment is 15-20 days.

Collection of herbs for the treatment of VSD

Make a mixture of the following herbs: marsh cudweed (30 gr.), Astragalus wooliflora (40 gr.), horsetail (40 gr.), sweet clover (40 gr.) Make a decoction from the mixture and take 15 - 30 ml (1- 2 tablespoons) for 1-2 months.

Video: VSD, panic attacks. Occurrence and treatment.

Sympathetic system

Parasympathetic system

Dilates pupils Inhibits salivation Increases the frequency and strength of heart contractions Dilates bronchi and bronchioles Strengthens lung ventilation Inhibits intestinal motility and the production of digestive enzymes Increases blood pressure Increases blood volume by contracting the spleen Causes contraction of muscles that raise hair Constricts arterioles in the skin of the extremities Strengthens the reabsorption of water in the nephrons and reduces diuresis Causes the release of adrenaline from the adrenal glands

Constricts the pupils Stimulates salivation Reduces the frequency and force of heart contractions Dilates bronchi and bronchioles Reduces ventilation of the lungs Strengthens peristalsis and stimulates the production of digestive enzymes Reduces blood pressure Dilates arterioles in the facial skin

45. The main symptoms characteristic of the prevalence of the influences of the sympathetic and parasympathetic departments. “Vagotonia”, “sympathotonia”, “normotonia”.

DESCRIPTION

Vagotonia(obsolete; vagotonia; vago- + Greek tonos tension; synonym parasympathicotonia) - the predominance of the tone of the parasympathetic part of the autonomic nervous system over the tone of its sympathetic part. Manifested by bradycardia, decreased blood pressure, hypoglycemia(, a pathological condition characterized by a decrease in blood glucose concentration below 3.5 mmol/l, peripheral blood below normal, resulting in hypoglycemic syndrome .), hyperhidrosis (increased sweating).

CAUSES

The most common causes of vagotonia development are

neuroses,
mild organic lesions brain,
stem and hypothalamic disorders.

SYMPTOMS

cold and damp skin,
sweating,
hypersalivation, Hypersalivation (another name is ptyalism) - increased secretion salivary secretion due to increased activity of the salivary glands.
bradycardia,(Bradycardia - this is a violation of the heart rhythm (arrhythmia) in the direction of reducing the contraction frequency. Normally, the frequency of contractions in adults ranges from 60-80 (at rest) and up to 140 (at physical activity) once per minute. A pulse below 60 times per minute is considered rare and such a heart rhythm disorder is called bradycardia.)
tendency towards orthostatic hypotension, This long-term condition, characterized by low blood pressure - less than 100/60 mmHg. due to decreased vascular tone. Previously, the term vegetative-vascular dystonia (VSD) was used for the hypotonic type.
respiratory arrhythmia,
tendency to faint.

Patients are slow, phlegmatic, indecisive, prone to depression, and have little endurance.

Vagotonia manifested by disturbances in the functioning of the respiratory system, periodic sensations of lack of air and poor tolerance of low temperatures. Disorders may occur digestive system– diarrhea or constipation, abdominal pain, various allergic reactions, swelling under the eyes. All these symptoms can appear either periodically or constantly. There are frequent night pains – in the legs and abdomen.

Vagotonia often accompanied by various cardiovascular disorders. First of all, these are pain in the heart area, low blood pressure or sudden periodic drops in pressure. In this case, the heart has a reduced tone, the number of beats per minute can decrease to 40-50 instead of the normal 65-70 for a child, but the physical size of the heart muscle can be increased. In addition, bradyarrhythmia - irregularities in the heart rhythm - can be periodically recorded.

TREATMENT

Drug therapy is prescribed in combination with non-drug drugs or if the latter are ineffective.

Treatment should begin with herbal preparations that have the least side effects. Considering the duration of treatment, several medications should not be prescribed at the same time; it is advisable to replace one drug with another.

Sympathotonia(overpriced sympathetic tone) People with sympathicotonia are characterized by temperament, ardor, volatility of mood, excessive affectivity towards pain, and neurotic states. Objectively, more frequent beating and breathing, increased blood pressure, pale skin, chill-like hyperkinesis (involuntary movements in various muscle groups) are determined.

Normotonia?

46. Basic functional tests aimed at diagnosing the prevalence of influences of the sympathetic and parasympathetic departments

Sympathicotonia

(sympathicotonia; Sympathico- + Greek tonos tension)

the predominance of the tone of the sympathetic part of the autonomic nervous system over the tone of its parasympathetic part.Sympathicotonia – the relative predominance of the tone of the sympathetic department of the autonomic nervous system over the parasympathetic, for example, in melancholic depression, manifested by symptoms such as mydriasis, tachycardia, a tendency to arterial hypertension, dry mucous membranes, pallor of the skin, a tendency to constipation, decreased secretion of tears, etc. ). In psychopathology, symptoms of sympathicotonia are most often accompanied or manifested by melancholy, melancholic and, possibly, hidden depression.

49. The main differences in the mechanism of information processing by the right and left hemispheres of the human brain

The brain consists of two hemispheres, left and right. The cortex of one hemisphere is not connected to the cortex of the other. Information is exchanged between the hemispheres through corpus callosum. If we draw an analogy with a computer, the left hemisphere of the brain functions as a serial processor. Information is processed by the left hemisphere in stages. The right hemisphere works as a parallel processor; it can process a lot of different information simultaneously. Left hemisphere responsible for logic and analysis. It is this that analyzes all the facts and systematizes them. The right hemisphere thinks in images, intuition, fantasies and dreams are in its power.

According to all the laws of general symmetry of the human body, the left and right hemispheres are almost exact mirror images of the other. Both hemispheres are responsible for controlling and controlling the basic movements of the human body and its sensory functions, with the right hemisphere controlling right side human body, and the left - the left.

There are several types of functional organization of the two hemispheres of the brain:

dominance of the left hemisphere - the verbal and logical nature of cognitive processes, a tendency to abstraction and generalization (left-hemisphere people);

dominance of the right hemisphere - concrete-figurative thinking, developed imagination(right-hemisphere people);

lack of pronounced dominance of one of the hemispheres (equihemispheric people).

Slightly less than half of people belong to unilaterally represented right-hemisphere and left-hemisphere response types.

50. Manifestations of functional asymmetry of the brain.

Functional asymmetry of the cerebral hemispheres, understood as the participation of the left or right hemispheres of different nature and unequal importance in the implementation of mental function, is not global, but partial in nature. In different systems, the nature of functional asymmetry may be different. As is known, motor, sensory and “mental” asymmetries are distinguished, and each of these asymmetries is divided into many partial types. Within motor asymmetries, manual (manual), foot, oral, oculomotor, etc. can be distinguished. Manual asymmetries are considered to be the leading among motor asymmetries, but other types of motor asymmetries and their connection with manual asymmetries have not yet been sufficiently studied. Sensory forms of asymmetry include visual, auditory, tactile, olfactory, etc. “Mental” forms include asymmetry in the brain organization of speech and other higher mental functions (perceptive, mnestic, intellectual).

Analyzing the relationship of only three types of asymmetries (hand - eye - ear), A.P. Chuprikov and his colleagues identified 8 variants of functional brain asymmetries in the normal population. When taking into account other types of motor and sensory asymmetries, their number should be many times greater.

Thus, there are many variants of normal functional asymmetry of the cerebral hemispheres when assessing even only elementary motor and sensory processes. An even greater variety of asymmetry options will be revealed if the characteristics of all higher mental functions are taken into account. Introduction to right-handed people (with presenter right hand) as a homogeneous group of the population is unlawful. Even more complex and homogeneous are the groups of left-handers (with the leading left hand) and ambidextrous people (with the leading both hands).

The real picture of asymmetries and their combinations in normal conditions is very complex. Of course, only “asymmetry profiles” (i.e., certain combinations, patterns of asymmetries of different functions) are very diverse. Their study is one of the most important tasks of modern natural science, including neuropsychology.

Each specific form of functional asymmetry is characterized by a certain degree, measure. Taking into account quantitative indicators, we can talk about strong or weak (motor or sensory) asymmetry. For precise characteristics the degree of expression of a particular asymmetry, some authors use such indicators as the asymmetry coefficient. Therefore, partial characteristics of asymmetry must be supplemented with quantitative data.

Functional asymmetry of the cerebral hemispheres in an adult is a product of the action of biosocial mechanisms. As studies conducted on children have shown, the foundations of the functional specialization of the hemispheres are innate, however, as the child develops, the mechanisms of interhemispheric asymmetry and interhemispheric interaction improve and become more complex. This fact is also noted in the indicators bioelectrical activity brain, and according to experimental psychological indicators, in particular, using the dichotic listening technique. The asymmetry of bioelectrical indicators manifests itself in the motor and sensory areas of the cortex earlier than others, and later in the associative (prefrontal and posterior-parietal-temporal) areas of the cerebral cortex. There is evidence of a decrease in EEG indicators of asymmetry in old age. Thus, there is an ontogenetic and generally age factor that determines the nature of functional asymmetry.Functional asymmetry of the brain – this is a complex property of the brain, reflecting the difference in the distribution of neuropsychic functions between its right and left hemispheres.

The study of interhemispheric differences is of great importance for solving problems in education. According to Joseph Bogen, the current emphasis in the educational system on the acquisition of verbal skills and the development of analytical thinking causes neglect of the development of important non-verbal abilities. And under such conditions, one half of the brain is “starved” and its potential contribution to the development of the individual as a whole is ignored.

According to Springer and Deitch, the study of laterality should be in those directions that relate to dexterity and spatial orientation, it should be an indispensable factor in assessing the school maturity of a child upon entering school. It is important in all cases: educational difficulties, behavioral disorders. It is necessary to carefully study the state of the child’s health, organ functions, motor skills - here the problem of laterality arises - the manifestation of the action and interaction of the cerebral hemispheres.

Research on brain asymmetry has sparked interest in the general problem of right-handedness and left-handedness and has shown differences between left- and right-handed people in brain organization, leading to a number of questions: what are the implications of these differences, if any, for intelligence, creativity?

What factors primarily determine left-handedness (genes, life experience, minor brain damage)?

The problem of functional asymmetry of the cerebral hemispheres is very complex because differences in the functioning of the left and right hemispheres are masked by redundancy brain activity providing duplication and increasing its reliability.

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“A living organism is more than the sum of its parts.” Life processes in individual organs are united by higher regulatory mechanisms into a wonderful whole, full of deep meaning, without which maintaining life would be impossible.

The autonomic nervous system is part of these regulatory mechanisms. In a complex interaction, it is closely related to the endocrine glands and many other regulatory apparatuses of vegetative functions (mineral, vitamin, acid-base balance etc.), which ensures the integrity and consistency of all functions within the body itself.

In contrast, the central nervous system regulates the active and passive interactions of the body with the outside world, which, through positive and negative impulses arising in the brain, are decisive in the nervous regulation of autonomic functions. At the same time, the interstitial brain is the center of the unified regulation of the most important vegetative processes in the body: blood circulation, respiration, metabolism, blood system, water metabolism and heat regulation.

Bykov, continuing his work on the conditioned reflexes of his great teacher Pavlov, proved that all reflex processes of nervous activity in the body proceed through the mechanism of conditioned reflexes, i.e. through the cerebral cortex, which is capable of establishing time-limited connections with any part of the body and such ensure its adaptation to the constantly changing conditions of the internal and external environment.

With such diverse interconnections, relationships and continuously changing interactions, a number of difficulties are created in conducting functional tests autonomic nervous system. The main disadvantage of most of these tests is the lack of sufficient specificity. The action of a given stimulus in one part of the autonomic regulatory mechanism often causes the entire functional system. Therefore, almost all tests for the study of the autonomic nervous system suffer from certain shortcomings from the very beginning. Thus, the values of blood pressure, blood sugar or pulse rate detected at rest in no way give the right to draw any conclusions about the state of compensatory processes, in relation to which the autonomic nervous system plays a leading role.

In addition, when conducting most functional tests, unilateral loads that are not encountered under normal conditions are used, which are also carried out in an environment (hospital) alien to the actual living conditions of the test subject. Moreover, most of the loads that are related to the profession or work are precisely absent in these samples.

Therefore, one usually has to be content with only a general statement of functional deviations of the autonomic nervous system from the norm. However, this is already valuable. Great importance It is also possible, with the help of some of these tests, to distinguish organic disorders from purely functional ones.

In the basic regulatory mechanisms of the autonomic nervous system, there is a polarity of two types of influences, which are generally antagonistic: the sympathetic and parasympathetic (vagus nerve) nervous system. Basically, all organs are supplied to the same extent with fibers from both departments. The predominance of the influence of one of the departments is clinically manifested by a number of symptoms, observation of which makes it possible to come to important conclusions regarding the functional state of autonomic regulation.

In the table on page Determination of the type of reactivity using anamnesis, this antagonism of the functions of the sympathetic and parasympathetic nervous system is clearly compared according to the data given by Hoff. Functional antagonism between the sympathetic and parasympathetic nervous systems does not have universal significance, since it is not found in a number of organs and is often absent even in organs with double autonomic innervation.

From among the numerous methods at our disposal for studying the functions of the autonomic nervous system, only a few have been selected and presented below, which have proven themselves in practice and do not require special equipment or high costs.

Carrying out functional tests requires strict adherence to certain general rules. In this case it is necessary:

a) Carefully establish initial values by conducting repeated tests on different days, if possible on an empty stomach, with the patient in complete physical and mental rest, without changing the therapeutic regimen (for example, prescribing or stopping treatment affecting the autonomic nervous system).

b) Always carry out tests at the same hours of the day (changes in the nature of autonomic reactions depending on fluctuations in the daily rhythm physiological functions) and with the same biological state of the body, especially in women.

c) To identify the nervous regulation of autonomic functions, it is not so much static indicators at a given moment (like a cross section), such as, for example, a single measurement of blood pressure or a single determination of blood sugar, that are suitable, but rather systematic observations of changes in a number of indicators in the form of daily, weekly and monthly curves (like a longitudinal section), giving a more complete picture. The most valuable insights can be obtained through stress testing. These loads can be either of a somatic nature (in the form of bending the knees, climbing stairs, exposure to cold and heat, etc., or in the form of using medications), or of a mental nature.

Sympathetic nervous system

Parasympathetic nervous system

Increasing minute volume, enhancing the function of automaticity, conductivity, contractility and excitability

Decrease in cardiac output, inhibition of automatic function, conductivity, contractility and excitability

Increased blood supply to working skeletal muscles.

Increased blood circulation in the coronary and pulmonary arteries, decreased blood supply to the skin and mucous membranes

Decreased blood supply to skeletal muscles

Reduced blood circulation in the coronary and pulmonary arteries, increased blood supply to the skin and mucous membranes

Increased excitability of the respiratory center

Increased tidal volume

Increasing blood supply and blood filling of the lungs

Decreased excitability of the respiratory center

Decreased tidal volume

Decreased blood supply and blood filling to the lungs

Energy consumption, decay processes

Increase metabolism

Increased body temperature

Increased protein breakdown

Tendency towards acidosis

Decrease in K/Ca ratio

Conservation of energy, rest, synthesis processes

Decreased metabolism

Decreased body temperature

Minor protein breakdown

Tendency towards alkalosis

Increasing the K/Ca ratio

Release of blood from the depot

Increase in the number of red blood cells

Sympathetic nervous system

Tendency towards a shift towards myeloid elements in the white blood picture

Decreased eosinophil count

Accumulation of blood in the depot

Decreased red blood cell count

Parasympathetic nervous system

Tendency towards lymphatic cells in the white blood pattern

Increased number of eosinophils

Closing the entrance (cardia)

Stomach: weakening of tone and inhibition of peristalsis

Inhibition of secretion of the glands of the fundus of the stomach

Small and large intestines: decreased tone and inhibition of peristalsis

Opening the entrance (cardia)

Stomach: increased tone and increased peristalsis

Increased secretion of the glands of the fundus of the stomach

Small and large intestines: increased tone and increased peristalsis

Inhibition of insulin production and external secretion

Increased insulin secretion and external secretion

Widening of the palpebral fissure to bulging eyes (exophthalmos)

Narrowing of the palpebral fissure (enophthalmos)

Inhibition of urination, relaxation of the muscle that empties the bladder (m. detrusor)

Increased sphincter tone

Increased urination, increased tone of the muscle that empties the bladder (m. detrusor)

Vasodilation and erection

d) When stress tests it is necessary to pay attention to the exact dosage, as well as the speed of administration of a particular substance, and when repeating or conducting several tests, to a sufficient period of time between them. The reaction to the load must completely subside before starting a new test.

e) For evaluation general condition it is always necessary to carry out several additional research, suitable for clarifying the question posed to the researcher. In essence, almost all functional studies of individual organs, provided that they do not indicate damage to these organs, can also be used as functional tests of the autonomic nervous system.

f) When discussing the results, Wilder's law on initial quantities should be observed. According to this law, a person, even with strict adherence to experimental conditions, does not have a constant, characteristic reaction for a given person to substances acting on the sympathetic and parasympathetic parts of the nervous system. The more active a given organ is, the less its excitability in relation to activating influences and the greater its sensitivity in relation to inhibitory influences. When the initial value of stimulation reaches its maximum strength, excitability simultaneously becomes equal to zero, and vice versa.

When functional mobility immediately before excitation exceeds a certain limit, a paradoxical reaction occurs, possibly as a consequence of an antagonistic effect. This corresponds to those patterns that are designated as “restructuring”, “change in functional state”, “antagonistic regulation” and which are, as it were, a protective reaction of the body.

When discussing and assessing the results of tests on the function of the autonomic nervous system, it is recommended to proceed from the division of the initial reactive state according to Birkmeier-Winkler, according to which we distinguish:

a) Increased tone of the sympathetic nervous system, which is fixation increased arousal in the sympathetic nervous system (sympathicotonia - sympathicotonic reactive phase of switching of the autonomic nervous system).

Signs: test indicators are very labile, lying above the normal limits of fluctuations, hyper-regulatory (irritable) type under load.

b) A decrease in the tone of the sympathetic nervous system, which often occurs secondary to long-existing sympathicotonia and occurs when the sympathetic nervous system fails and is exhausted (Selie's state of exhaustion).

Signs: the readings of many samples are determined below the normal limits of fluctuation; lack of positive reactions after exercise; refractory (rigid) type or even paradoxical reactions; various vegetative functions often do not occur in parallel, but are dissociated.

c) Increased tone of the parasympathetic nervous system, which is expressed in the predominance of vagal innervation. Indicators of tests at rest are determined significantly below the norm, reactions to loads are similar to the type of reactions indicated in section “b”.

Despite this, after exercise there is not lability, but, on the contrary, stability of the ratios (for example, basal metabolism).

d) Amphotonia, which is characterized by the same degree of overstrain of both the sympathetic nervous system and vagus nerve. However, it is often impossible to clearly distinguish between these conditions, so in these cases we can only talk about a general functional disorder of the autonomic nervous system in the sense vegetative dystonia as a reactive state.

Physical and mental signs

Increased tone of the sympathetic nervous system

Increased tone of the parasympathetic nervous system

Decreased tone of the sympathetic nervous system

Short sleep or insomnia, late falling asleep, restless sleep, disturbing dreams

Deep, long, dreamless sleep; slow transition to wakefulness in the morning

Sleep is possible at any time of the day or night due to exhaustion of nervous activity

General health and ability to work

Variable ratios: relatively good performance, especially in the evening, high but short-term performance

Maximum performance before lunch, rapid decrease in energy. Long-term performance

Performance only for a short period: very rapid fatigue during physical and mental stress

For autonomic disorders caused by physical factors, the greatest performance is in the morning, and in case of vegetative disorders caused by mental issues, in the evening

Intolerance to excessively hot and crowded rooms, extreme cold; tendency to sweating or chilliness, as well as febrile infection

Feeling hot increased sensitivity to dry heated air

Chilling, great sensitivity to cold, often low temperature. Patients feel well only in warm rooms

Reduced excitability, but extremely increased sensitivity; need for peace and protection; ideas of depersonalization

Often complaints from the heart (palpitations, feeling of pressure, stabbing, squeezing).

Headaches in the evenings, flickering in the eyes, fog before the eyes, migraines

Feeling of a lump (globus) in the throat, dry mouth, hoarseness, especially when excited

Polyuria, decreased potency or libido, dysmenorrhea or amenorrhea

Cold hands and feet, numbness in the fingers at night, numbness and loss of strength in the hands and feet in the morning

In the foreground, depending on mental stress, complaints from the gastrointestinal tract (burning throat, nausea, cramping pain in the upper abdomen, diarrhea or constipation)

A feeling of tightness in the heart area combined with arrhythmias, especially at night and when lying down

Transient catarrh of the respiratory tract

Absence of potency disorders, sometimes early ejaculation (ejaculatio praecox)

Balance disturbances with darkening of the eyes, rapid visual fatigue. When under strain, rapid fatigue, palpitations and shortness of breath. Feeling of pressure after eating, constipation. Significant potency disorders with weakened libido in both sexes

Picture of functional state and compensatory capabilities of the autonomic nervous system is of practical importance for the doctor. By objectively identifying dysfunctions of the autonomic nervous system, it is possible to make a more correct judgment about patients with complaints who do not have significant changes in the organs, and based on the data of determining the nature of the reactive state, justify the choice of a drug and its dosage.

Tone of the autonomic nervous system

The autonomic or autonomic nervous system is usually contrasted with the anomalous or cerebrospinal nervous system. The latter innervates mainly the sensory organs and organs of movement, i.e., all striated muscles; its innervation is strictly segmental, and the nerve fibers come from the nerve centers ( nerve cell) to the working body without interruptions. The autonomic nervous system innervates primarily smooth muscles, glands and internal organs of the body (circulatory, respiratory, gastrointestinal tract, liver, kidneys, etc.), the innervation is non-segmental and with mandatory breaks. Thus, the main function of the cerebrospinal nervous system is to regulate the relationship between the body and environment, the main function of the autonomic nervous system is to regulate the relationships and processes within the body. But it goes without saying that both the cerebrospinal and autonomic nervous systems are only parts of a single whole - the unified nervous system of the body. They are related to each other both morphologically and functionally. Therefore, all organs of our body have double - autonomic and cerebrospinal innervation. In this way, with the indispensable participation of internal secretion, which in turn is closely connected with the autonomic nervous system, the unity and integrity of the entire organism is achieved.

Tone of the autonomic nervous system

Under natural conditions, the sympathetic and parasympathetic centers of the autonomic nervous system are in a state of continuous excitation, called “tone.” The phenomenon constant tone The autonomic nervous system manifests itself primarily in the fact that a constant flow of impulses with a certain repetition frequency flows along the efferent fibers to the organs. It is known that the state of tone parasympathetic system best reflects the activity of the heart, especially heart rate, and the state of the tone of the sympathetic system - vascular system, in particular, the value of blood pressure (at rest or when performing functional tests). Many aspects of the nature of tonic activity remain little known. It is believed that the tone of nuclear formations is formed mainly due to the influx of sensory information from reflexogenic zones, individual groups of interoreceptors, as well as somatic receptors. At the same time, the existence of our own pacemakers - pacemakers, localized mainly in medulla oblongata. The nature of the tonic activity of the sympathetic, parasympathetic and metasympathetic parts of the autonomic nervous system can also be associated with the level of endogenous modulators (direct and indirect action), adrenoreactivity, cholinoreactivity and other types of chemoreactivity. The tone of the autonomic nervous system should be considered as one of the manifestations of the homeostatic state and at the same time one of the mechanisms for its stabilization.

Constitutional classification of ANS tone in humans

The predominance of tonic influences of the parasympathetic and sympathetic parts of the autonomic nervous system served as the basis for the creation of a constitutional classification. Back in 1910, Eppinger and Hess created the doctrine of sympathicotonia and vagotonia. They divided all people into two categories - sympathicotonics and vagotonics. They considered signs of vagotonia to be a rare pulse, deep slow breathing, decreased blood pressure, narrowing of the palpebral fissure and pupils, a tendency to hypersalivation and flatulence. Now there are already more than 50 signs of vagotonia and sympathicotonia (only 16% of healthy people can identify sympathicotonia or vagotonia). IN Lately A.M. Greenberg proposes to distinguish seven types of autonomic reactivity: general sympathicotonia; partial sympathicotonia; general vagotonia; partial vagotonia; mixed reaction; general intense reaction; general weak reaction.

The question of the tone of the autonomic (autonomic) nervous system requires additional research, especially taking into account the great interest shown in it in medicine, physiology, psychology and pedagogy. It is believed that the tone of the autonomic nervous system reflects the process of biological and social adaptation of a person to various environmental conditions and lifestyle. Assessing the tone of the autonomic nervous system is one of the difficult tasks of physiology and medicine. There are special research methods autonomic tone. For example, when examining cutaneous autonomic reflexes, in particular the pilomotor reflex, or the “goose bumps” reflex (it is caused by painful or cold irritation of the skin in the area of the trapezius muscle), with a normotonic type of reaction in healthy people, the formation of “goose bumps” occurs. When the lateral horns, anterior roots of the spinal cord and the borderline sympathetic trunk are affected, this reflex is absent. When studying the sweat reflex, or aspirin test (ingestion of 1 g of aspirin dissolved in a glass of hot tea) healthy person diffuse sweating appears (positive aspirin test). If the hypothalamus or the pathways connecting the hypothalamus with the sympathetic neurons of the spinal cord are damaged, diffuse sweating is absent (negative aspirin test).

When assessing vascular reflexes, local dermographism is often examined, i.e. vascular response to stroke irritation of the skin of the forearm or other parts of the body with the handle of a neurological hammer. With mild skin irritation, a white stripe appears after a few seconds in normotensive patients, which is explained by a spasm of the superficial skin vessels. If the irritation is applied more strongly and slowly, then in normotensive patients a red stripe appears, surrounded by a narrow white border - this is local red dermographism, which occurs in response to a decrease in sympathetic vasoconstrictor effects on the vessels of the skin. With increased tone of the sympathetic department, both types of irritation cause only a white stripe (local white dermographism), and with an increase in the tone of the parasympathetic system, i.e. with vagotonia, in humans, both types of irritation (both weak and strong) cause red dermographism.

Prevel's orthostatic reflex consists of the active transfer of the subject from horizontal position in a vertical position, with pulse counting before the start of the test and 10–25 s after its completion. With a normotonic type of reaction, the heart rate increases by 6 beats per minute. A higher increase in heart rate indicates a sympathetic-tonic type of reaction, while a slight increase in heart rate (no more than 6 beats per minute) or a constant pulse indicates increased tone of the parasympathetic department.

When studying painful dermographism, i.e. When the skin is irritated with a sharp pin, a red stripe 1–2 cm wide appears on the skin of normotensive patients, surrounded by narrow white lines. This reflex is caused by a decrease in tonic sympathetic influences on the vessels of the skin. However, it does not occur when the vasodilator fibers going to the vessel as part of the peripheral nerve are damaged, or when the depressor part of the bulbar vasomotor center is damaged.

Symptoms of diseases of the autonomic nervous system

P. S. Medovik points out the connection between the development of pneumonia and the impaired tone of the autonomic nervous system. In his opinion, vasomotor disorders, due to disturbances in the autonomic-endocrine system, are the main cause of the development of pneumonia. The opinion that disorders in the blood circulation and edema are the cause of pneumonia is also supported by A. A. Speransky, D. S. Sarkisov and others. They believe that various effects on the nervous system cause disorders in the blood circulation of the lungs or swelling in them, which subsequently leads to the development of a pneumonic process.

Chapter 17. Antihypertensive drugs

Antihypertensive drugs are called medicinal substances, which lower blood pressure. Most often they are used for arterial hypertension, i.e. with high blood pressure. Therefore, this group of substances is also called antihypertensive drugs.

Arterial hypertension is a symptom of many diseases. There are primary arterial hypertension, or hypertension (essential hypertension), as well as secondary (symptomatic) hypertension, for example, arterial hypertension with glomerulonephritis and nephrotic syndrome (renal hypertension), with narrowing renal arteries(renovascular hypertension), pheochromocytoma, hyperaldosteronism, etc.

In all cases, they strive to cure the underlying disease. But even if this fails, arterial hypertension should be eliminated, since arterial hypertension contributes to the development of atherosclerosis, angina pectoris, myocardial infarction, heart failure, visual impairment, and renal dysfunction. A sharp increase in blood pressure - a hypertensive crisis can lead to bleeding in the brain (hemorrhagic stroke).

At various diseases The causes of arterial hypertension are varied. IN initial stage hypertension is associated with an increase in the tone of the sympathetic nervous system, which leads to an increase in cardiac output and constriction of blood vessels. In this case, blood pressure is effectively reduced by substances that reduce the influence of the sympathetic nervous system (central-acting antihypertensives, adrenergic blockers).

In kidney disease and in the late stages of hypertension, an increase in blood pressure is associated with activation of the renin-angiotensin system. The resulting angiotensin II constricts blood vessels, stimulates sympathetic system, increases the release of aldosterone, which increases the reabsorption of Na + ions in the renal tubules and thus retains sodium in the body. Drugs that reduce the activity of the renin-angiotensin system should be prescribed.

With pheochromocytoma (tumor medulla adrenal glands), adrenaline and norepinephrine secreted by the tumor stimulate the heart and constrict blood vessels. Pheochromocytoma is removed surgically, but before surgery, during surgery, or if surgery is not possible, blood pressure is reduced with the help of wasp-blockers.

A common cause of arterial hypertension may be sodium retention in the body due to excessive consumption of table salt and insufficiency of natriuretic factors. Increased content Na + in the smooth muscles of blood vessels leads to vasoconstriction (the function of the Na + /Ca 2+ exchanger is disrupted: the entry of Na + and the exit of Ca 2+ decreases; the level of Ca 2+ in the cytoplasm of smooth muscles increases). As a result, blood pressure increases. Therefore, for arterial hypertension, diuretics are often used that can remove excess sodium from the body.

For arterial hypertension of any origin, myotropic vasodilators have an antihypertensive effect.

It is believed that patients with arterial hypertension should use antihypertensive drugs systematically to prevent an increase in blood pressure. For this purpose, it is advisable to prescribe long-acting antihypertensive drugs. The most commonly used drugs are those that act for 24 hours and can be prescribed once a day (atenolol, amlodipine, enalapril, losartan, moxonidine).

IN practical medicine The most commonly used antihypertensive drugs are diuretics, β-blockers, calcium channel blockers, α-blockers, ACE inhibitors, and AT 1 receptor blockers.

To relieve hypertensive crises, diazoxide, clonidine, azamethonium, labetalol, sodium nitroprusside, and nitroglycerin are administered intravenously. For mild hypertensive crises, captopril and clonidine are prescribed sublingually.

Classification of antihypertensive drugs

I. Drugs that reduce the influence of the sympathetic nervous system (neurotropic antihypertensive drugs):

1) means of central action,

2) drugs that block sympathetic innervation.

P. Vasodilators of myotropic action:

2) activators of potassium channels,

3) drugs with an unclear mechanism of action.

III. Calcium channel blockers.

IV. Agents that reduce the effects of the renin-angiotensin system:

1) drugs that interfere with the formation of angiotensin II (drugs that reduce renin secretion, ACE inhibitors, vasopeptidase inhibitors),

2) AT 1 receptor blockers.

Drugs that reduce the influence of the sympathetic nervous system

(neurotropic antihypertensive drugs)

The higher centers of the sympathetic nervous system are located in the hypothalamus. From here, excitation is transmitted to the center of the sympathetic nervous system, located in the rostroventrolateral medulla oblongata (RVLM - rostro-ventrolateral medulla), traditionally called the vasomotor center. From this center, impulses are transmitted to the sympathetic centers of the spinal cord and further along the sympathetic innervation to the heart and blood vessels. Activation of this center leads to an increase in the frequency and strength of heart contractions (increased cardiac output) and to an increase in the tone of blood vessels - blood pressure increases.

Blood pressure can be reduced by inhibiting the centers of the sympathetic nervous system or by blocking sympathetic innervation. In accordance with this, neurotropic antihypertensive drugs are divided into central and peripheral agents.

TO centrally acting antihypertensive drugs include clonidine, moxonidine, guanfacine, methyldopa.

Clonidine (clonidine, hemitone) is an α2-adrenergic agonist, stimulates α2A-adrenergic receptors in the center of the baroreceptor reflex in the medulla oblongata (nucleus of the solitary tract). In this case, the vagal centers (nucleus ambiguus) and inhibitory neurons are excited, which have a depressing effect on the RVLM (vasomotor center). In addition, the inhibitory effect of clonidine on RVLM is due to the fact that clonidine stimulates I 1 -receptors (imidazoline receptors).

As a result, the inhibitory effect of the vagus on the heart increases and the stimulating effect of sympathetic innervation on the heart and blood vessels decreases. As a result, it decreases cardiac output and tone of blood vessels (arterial and venous) - blood pressure decreases.

Partly hypotensive effect Clonidine is associated with activation of presynaptic α2-adrenergic receptors at the endings of sympathetic adrenergic fibers - the release of norepinephrine decreases.

At higher doses, clonidine stimulates extrasynaptic a 2 B -adrenergic receptors of smooth muscles of blood vessels (Fig. 45) and with rapid intravenous administration can cause short-term vasoconstriction and an increase in blood pressure (therefore, intravenous clonidine is administered slowly, over 5-7 minutes).

Due to the activation of α2-adrenergic receptors in the central nervous system, clonidine has a pronounced sedative effect, potentiates the effect of ethanol, exhibits analgesic properties.

Clonidine is a highly active antihypertensive drug (therapeutic dose when administered orally 0.g); lasts about 12 hours. However, when used systematically, it can cause a subjectively unpleasant sedative effect (distracted thoughts, inability to concentrate), depression, decreased tolerance to alcohol, bradycardia, dry eyes, xerostomia (dry mouth), constipation, impotence. If you abruptly stop taking the drug, a pronounced withdrawal syndrome develops: after 18-25 hours, blood pressure rises, and a hypertensive crisis is possible. β-Adrenergic blockers increase clonidine withdrawal syndrome, so these drugs are not prescribed together.

Clonidine is used mainly to quickly lower blood pressure during hypertensive crises. In this case, clonidine is administered intravenously over 5-7 minutes; with rapid administration, an increase in blood pressure is possible due to stimulation of vascular α2-adrenergic receptors.

Clonidine solutions in the form of eye drops are used in the treatment of glaucoma (reduces the production of intraocular fluid).

Moxonidine (cynte) stimulates imidazoline 1 1 receptors and, to a lesser extent, a 2 adrenergic receptors in the medulla oblongata. As a result, the activity of the vasomotor center decreases, cardiac output and blood vessel tone decrease, and blood pressure decreases.

The drug is prescribed orally for the systematic treatment of arterial hypertension 1 time per day. In contrast to clonidine, moxonidine causes less pronounced sedation, dry mouth, constipation, and withdrawal symptoms.

Guanfacine (estulic), similar to clonidine, stimulates central α2-adrenergic receptors. Unlike clonidine, it does not affect 1 1 receptors. The duration of the hypotensive effect is about 24 hours. It is prescribed orally for the systematic treatment of arterial hypertension. Withdrawal syndrome is less pronounced than with clonidine.

Methyldopa (dopegite, aldomet) chemical structure is a-methyl-DOPA. The drug is prescribed orally. In the body, methyldopa is converted into methylnorepinephrine, and then into methyladrenaline, which stimulate the α2-adrenergic receptors of the baroreceptor reflex center.

The hypotensive effect of the drug develops after 3-4 hours and lasts about 24 hours.

Side effects of methyldopa: dizziness, sedation, depression, nasal congestion, bradycardia, dry mouth, nausea, constipation, liver dysfunction, leukopenia, thrombocytopenia. Due to the blocking effect of a-methyl-dopamine on dopaminergic transmission, the following are possible: parkinsonism, increased production of prolactin, galactorrhea, amenorrhea, impotence (prolactin inhibits the production of gonadotropic hormones). If you abruptly stop taking the drug, withdrawal symptoms appear after 48 hours.

Drugs that block peripheral sympathetic innervation.

To reduce blood pressure, sympathetic innervation can be blocked at the level of: 1) sympathetic ganglia, 2) endings of postganglionic sympathetic (adrenergic) fibers, 3) adrenergic receptors of the heart and blood vessels. Accordingly, ganglion blockers, sympatholytics, and adrenergic blockers are used.

Ganglioblockers- hexamethonium benzosulfonate (benzo-hexonium), azamethonium (pentamine), trimetaphan (arfonade) block the transmission of excitation in the sympathetic ganglia (block N N -xo-linoreceptors of ganglionic neurons), block N N -cholinergic receptors of chromaffin cells of the adrenal medulla and reduce the release of adrenaline and norepinephrine . Thus, ganglion blockers reduce the stimulatory effect of sympathetic innervation and catecholamines on the heart and blood vessels. There is a weakening of heart contractions and expansion of arterial and venous vessels - arterial and venous pressure decreases. At the same time, ganglion blockers block the parasympathetic ganglia; thus eliminating the inhibitory effect of the vagus nerves on the heart and usually causing tachycardia.

For systematic use, ganglion blockers are of little use due to side effects (severe orthostatic hypotension, impaired accommodation, dry mouth, tachycardia; possible intestinal atony and Bladder, sexual dysfunction).

Hexamethonium and azamethonium act for 2.5-3 hours; administered intramuscularly or subcutaneously during hypertensive crises. Azamethonium is also administered intravenously slowly in 20 ml of isotonic sodium chloride solution for hypertensive crisis, edema of the brain, lungs against the background of high blood pressure, for spasms of peripheral vessels, for intestinal, hepatic or renal colic.

Trimetaphan acts for 10-15 minutes; administered in solutions intravenously by drip for controlled hypotension during surgical operations.

Sympatholytics- reserpine, guanethidine (octadine) reduce the release of norepinephrine from the endings of sympathetic fibers and thus reduce the stimulating effect of sympathetic innervation on the heart and blood vessels - arterial and venous pressure decreases. Reserpine reduces the content of norepinephrine, dopamine and serotonin in the central nervous system, as well as the content of adrenaline and norepinephrine in the adrenal glands. Guanethidine does not penetrate the blood-brain barrier and does not change the content of catecholamines in the adrenal glands.

Both drugs differ in their duration of action: after stopping systematic use, the hypotensive effect can last up to 2 weeks. Guanethidine is much more effective than reserpine, but is rarely used due to severe side effects.

Due to the selective blockade of sympathetic innervation, the influences of the parasympathetic nervous system predominate. Therefore, when using sympatholytics, the following are possible: bradycardia, increased secretion of NS1 (contraindicated in peptic ulcer), diarrhea. Guanethidine causes significant orthostatic hypotension (associated with a decrease in venous pressure); When using reserpine, orthostatic hypotension is mild. Reserpine reduces the level of monoamines in the central nervous system and can cause sedation and depression.

A -Adrenergic blockers reduce the stimulating effect of sympathetic innervation on blood vessels (arteries and veins). Due to the dilation of blood vessels, arterial and venous pressure decreases; heart contractions reflexively become more frequent.

a 1 -Adrenergic blockers - prazosin (minipress), doxazosin, terazosin are prescribed orally for the systematic treatment of arterial hypertension. Prazosin acts for 10-12 hours, doxazosin and terazosin - 18-24 hours.

Side effects of a 1 -blockers: dizziness, nasal congestion, moderate orthostatic hypotension, tachycardia, frequent urination.

a 1 a 2 -The adrenergic blocker phentolamine is used for pheochromocytoma before surgery and during surgery to remove pheochromocytoma, as well as in cases where surgery is impossible.

β -Adrenergic blockers- one of the most commonly used groups of antihypertensive drugs. When used systematically, they cause a persistent hypotensive effect, prevent sudden increases in blood pressure, practically do not cause orthostatic hypotension, and, in addition to hypotensive properties, have antianginal and antiarrhythmic properties.

β-Adrenergic blockers weaken and slow down heart contractions - systolic blood pressure decreases. At the same time, β-adrenergic blockers narrow blood vessels (block of β 2 -adrenergic receptors). Therefore, with a single use of beta-blockers, the mean arterial pressure usually decreases slightly (with isolated systolic hypertension, blood pressure can decrease even after a single use of beta-blockers).

However, if p-blockers are used systematically, then after 1-2 weeks the narrowing of blood vessels is replaced by their dilation - blood pressure decreases. Vasodilation is explained by the fact that with the systematic use of beta-blockers, due to a decrease in cardiac output, the baroreceptor depressor reflex is restored, which is weakened in arterial hypertension. In addition, vasodilation is facilitated by a decrease in the secretion of renin by juxtaglomerular cells of the kidneys (block of β 1 -adrenergic receptors), as well as blockade of presynaptic β 2 -adrenergic receptors in the endings of adrenergic fibers and a decrease in the release of norepinephrine.

For the systematic treatment of arterial hypertension, long-acting β 1 -blockers are often used - atenolol (tenormin; lasts about 24 hours), betaxolol (lasts up to 36 hours).

Side effects of β-blockers: bradycardia, heart failure, difficulty in atrioventricular conduction, decreased HDL levels in the blood plasma, increased bronchial and peripheral vascular tone (less pronounced with β 1 -blockers), increased effect of hypoglycemic agents, decreased physical activity.

a 2 β -Adrenergic blockers- labetalol (trandate), carvedilol (dilatrend) reduce cardiac output (block of β-adrenoreceptors) and reduce the tone of peripheral vessels (block of α-adrenoreceptors). The drugs are used orally for the systematic treatment of arterial hypertension. Labetalol is also administered intravenously during hypertensive crises.

Carvedilol is also used for chronic heart failure.

Chapter 17. Antihypertensive drugs

Antihypertensives are drugs that lower blood pressure. Most often they are used for arterial hypertension, i.e. with high blood pressure. Therefore, this group of substances is also called antihypertensive drugs.

Arterial hypertension is a symptom of many diseases. There are primary arterial hypertension, or hypertension (essential hypertension), as well as secondary (symptomatic) hypertension, for example, arterial hypertension with glomerulonephritis and nephrotic syndrome (renal hypertension), with narrowing of the renal arteries (renovascular hypertension), pheochromocytoma, hyperaldosteronism, etc.

The causes of arterial hypertension are different for different diseases. In the initial stage of hypertension, arterial hypertension is associated with an increase in the tone of the sympathetic nervous system, which leads to an increase in cardiac output and constriction of blood vessels. In this case, blood pressure is effectively reduced by substances that reduce the influence of the sympathetic nervous system (central-acting antihypertensives, adrenergic blockers).

In kidney disease and in the late stages of hypertension, an increase in blood pressure is associated with activation of the renin-angiotensin system. The resulting angiotensin II constricts blood vessels, stimulates the sympathetic system, increases the release of aldosterone, which increases the reabsorption of Na + ions in the renal tubules and thus retains sodium in the body. Drugs that reduce the activity of the renin-angiotensin system should be prescribed.

With pheochromocytoma (tumor of the adrenal medulla), adrenaline and norepinephrine secreted by the tumor stimulate the heart and constrict blood vessels. Pheochromocytoma is removed surgically, but before surgery, during surgery, or if surgery is not possible, blood pressure is reduced with the help of wasp-blockers.

A common cause of arterial hypertension may be sodium retention in the body due to excessive consumption of table salt and insufficiency of natriuretic factors. An increased content of Na + in the smooth muscles of blood vessels leads to vasoconstriction (the function of the Na + /Ca 2+ exchanger is impaired: the entry of Na + and the exit of Ca 2+ decreases; the level of Ca 2+ in the cytoplasm of smooth muscles increases). As a result, blood pressure increases. Therefore, for arterial hypertension, diuretics are often used that can remove excess sodium from the body.

For arterial hypertension of any origin, myotropic vasodilators have an antihypertensive effect.

In practical medicine, the most commonly used antihypertensive drugs are diuretics, β-blockers, calcium channel blockers, α-blockers, ACE inhibitors, and AT 1 receptor blockers.

Classification of antihypertensive drugs

I. Drugs that reduce the influence of the sympathetic nervous system (neurotropic antihypertensive drugs):

1) means of central action,

2) drugs that block sympathetic innervation.

P. Vasodilators of myotropic action:

1) donors N0,

2) activators of potassium channels,

3) drugs with an unclear mechanism of action.

III. Calcium channel blockers.

IV. Agents that reduce the effects of the renin-angiotensin system:

1) drugs that interfere with the formation of angiotensin II (drugs that reduce renin secretion, ACE inhibitors, vasopeptidase inhibitors),

2) AT 1 receptor blockers.

V. Diuretics.

Drugs that reduce the influence of the sympathetic nervous system

(neurotropic antihypertensive drugs)

TO centrally acting antihypertensive drugs include clonidine, moxonidine, guanfacine, methyldopa.

As a result, the inhibitory effect of the vagus on the heart increases and the stimulating effect of sympathetic innervation on the heart and blood vessels decreases. As a result, cardiac output and the tone of blood vessels (arterial and venous) decrease - blood pressure decreases.

Partly, the hypotensive effect of clonidine is associated with the activation of presynaptic α2-adrenergic receptors at the endings of sympathetic adrenergic fibers - the release of norepinephrine decreases.

In higher doses, clonidine stimulates extrasynaptic a 2 B -adrenergic receptors of smooth muscles of blood vessels (Fig. 45) and, with rapid intravenous administration, can cause short-term vasoconstriction and an increase in blood pressure (therefore, intravenous clonidine is administered slowly, over 5-7 minutes).

Due to the activation of α2-adrenergic receptors in the central nervous system, clonidine has a pronounced sedative effect, potentiates the effect of ethanol, and exhibits analgesic properties.

Clonidine is a highly active antihypertensive drug (therapeutic dose when administered orally 0.000075 g); lasts about 12 hours. However, when used systematically, it can cause a subjectively unpleasant sedative effect (distracted thoughts, inability to concentrate), depression, decreased tolerance to alcohol, bradycardia, dry eyes, xerostomia (dry mouth), constipation, impotence. If you abruptly stop taking the drug, a pronounced withdrawal syndrome develops: after 18-25 hours, blood pressure rises, and a hypertensive crisis is possible. β-Adrenergic blockers increase clonidine withdrawal syndrome, so these drugs are not prescribed together.

Clonidine solutions in the form of eye drops are used in the treatment of glaucoma (reduces the production of intraocular fluid).

Moxonidine(cint) stimulates imidazoline 1 1 receptors and, to a lesser extent, a 2 adrenergic receptors in the medulla oblongata. As a result, the activity of the vasomotor center decreases, cardiac output and blood vessel tone decrease, and blood pressure decreases.

Guanfatsin(estulik) similarly to clonidine stimulates central α2-adrenergic receptors. Unlike clonidine, it does not affect 1 1 receptors. The duration of the hypotensive effect is about 24 hours. It is prescribed orally for the systematic treatment of arterial hypertension. Withdrawal syndrome is less pronounced than with clonidine.

Methyldopa(dopegite, aldomet) chemical structure - a-methyl-DOPA. The drug is prescribed orally. In the body, methyldopa is converted into methylnorepinephrine, and then into methyladrenaline, which stimulate the α2-adrenergic receptors of the baroreceptor reflex center.

Metabolism of methyldopa

The hypotensive effect of the drug develops after 3-4 hours and lasts about 24 hours.

Drugs that block peripheral sympathetic innervation.

Ganglioblockers - hexamethonium benzosulfonate(benzo-hexonium), azamethonium(pentamine), trimethaphan(arfonade) block the transmission of excitation in the sympathetic ganglia (block N N -xo-linoreceptors of ganglionic neurons), block N N -cholinergic receptors of chromaffin cells of the adrenal medulla and reduce the release of adrenaline and norepinephrine. Thus, ganglion blockers reduce the stimulatory effect of sympathetic innervation and catecholamines on the heart and blood vessels. There is a weakening of heart contractions and expansion of arterial and venous vessels - arterial and venous pressure decreases. At the same time, ganglion blockers block the parasympathetic ganglia; thus eliminating the inhibitory effect of the vagus nerves on the heart and usually causing tachycardia.

Trimetaphan acts for 10-15 minutes; administered in solutions intravenously by drip for controlled hypotension during surgical operations.

Sympatholytics- reserpine, guanethidine(octadine) reduce the release of norepinephrine from the endings of sympathetic fibers and thus reduce the stimulating effect of sympathetic innervation on the heart and blood vessels - arterial and venous pressure decreases. Reserpine reduces the content of norepinephrine, dopamine and serotonin in the central nervous system, as well as the content of adrenaline and norepinephrine in the adrenal glands. Guanethidine does not penetrate the blood-brain barrier and does not change the content of catecholamines in the adrenal glands.

Due to the selective blockade of sympathetic innervation, the influences of the parasympathetic nervous system predominate. Therefore, when using sympatholytics, the following are possible: bradycardia, increased secretion of HC1 (contraindicated in peptic ulcers), diarrhea. Guanethidine causes significant orthostatic hypotension (associated with a decrease in venous pressure); When using reserpine, orthostatic hypotension is mild. Reserpine reduces the level of monoamines in the central nervous system and can cause sedation and depression.

a 1 -Adrenergic blockers - prazosin(minipress), doxazosin, terazosin prescribed orally for the systematic treatment of arterial hypertension. Prazosin acts for 10-12 hours, doxazosin and terazosin - 18-24 hours.

Side effects of a 1 -blockers: dizziness, nasal congestion, moderate orthostatic hypotension, tachycardia, frequent urination.

a 1 a 2 -Adrenergic blocker phentolamine used for pheochromocytoma before surgery and during surgery to remove pheochromocytoma, as well as in cases where surgery is impossible.

For the systematic treatment of arterial hypertension, long-acting β 1-blockers are often used - atenolol(tenormin; lasts about 24 hours), betaxolol(valid up to 36 hours).

a 2 β -Adrenergic blockers - labetalol(trandate), carvedilol(Dilatrend) reduce cardiac output (block of β-adrenoreceptors) and reduce the tone of peripheral vessels (block of α-adrenoreceptors). The drugs are used orally for the systematic treatment of arterial hypertension. Labetalol is also administered intravenously during hypertensive crises.

Carvedilol is also used for chronic heart failure.

Under the influence of the autonomic nervous system, a complex process of regulating all internal processes of the body occurs. The autonomic nervous system ensures consistency internal environment body. Vegetative-neural influences extend to all organs and tissues. The term “autonomic nervous system” reflects the control of involuntary functions of the body. The autonomic nervous system is dependent on the higher centers of the nervous system. There are sympathetic and parasympathetic parts of the autonomic nervous system. Their main difference lies in the functional innervation and is determined by the relationship to the means affecting the autonomic nervous system. The sympathetic part is excited by adrenaline, and the parasympathetic part by acetylcholine. Ergotamine has an inhibitory effect on the sympathetic part, and atropine has an inhibitory effect on the parasympathetic part.

Sympathetic division of the autonomic nervous system

The main formations of the sympathetic part are located mainly in the cerebral cortex, as well as in the spinal cord (in the lateral horns). In the spinal cord, the peripheral formations of the sympathetic division of the autonomic nervous system begin from the lateral horns. The sympathetic trunk is located along the lateral surface of the spinal column. The sympathetic trunk has 24 pairs of sympathetic nodes.

Parasympathetic part of the autonomic nervous system

The formations of the parasympathetic part begin from the cerebral cortex. The craniobulbar region is distinguished in the brain and the sacral region in the spinal cord. In the craniobulbar department there are:

1) the system of visceral nuclei (III nerve), namely paired small-celled nuclei, which are related to the innervation of the pupil (smooth muscle), and an unpaired small-celled accommodative nucleus, which provides innervation to smooth muscle - in the bottom of the Sylvian aqueduct, under the anterior tubercles of the quadrigeminal tubercles;

2) secretory lacrimal cells in the nuclear system facial nerve(VII nerve), located in the pons;

3) secretory salivary nucleus in the system of the glossopharyngeal nerve (IX nerve) – for parotid gland and XIII nerve - for the submandibular and sublingual salivary glands - in the medulla oblongata;

4) the visceral nuclei of the vagus nerve in the medulla oblongata, which innervate the heart, bronchi, gastrointestinal tract, digestive glands, and other internal organs.

Features of autonomic innervation

All organs of our body are under the influence of the autonomic nervous system (both of its parts). The sympathetic part changes the functional abilities of organs. Both parts of the autonomic nervous system are interconnected. But there are conditions when one part of the system prevails over the other. Vagotonia (predominance of the parasympathetic part) is characterized by narrow pupils, moist, bluish skin, bradycardia, low blood pressure, constricted (asthmatic) breathing, profuse salivation, increased acidity of gastric juice, a tendency to spasms of the esophagus, stomach, spastic constipation alternating with diarrhea, decreased metabolism, a tendency to obesity. The state of vagotonia is typical, for example, for a sleeping person. Sympathicotonia (predominance of the sympathetic part) is characterized by shiny, convex eyes with wide pupils; pale, dry skin with a tendency to piloarrection; tachycardia, high blood pressure, free breathing; dry mouth, achylia, dilation of the stomach, atonic constipation; brisk metabolism, tendency to lose weight. The state of sympathicotonia is characteristic, for example, of affective states (fear, anger, etc.).

How does the autonomic nervous system affect the body? Conditions are possible in which the activity of individual organs or systems of the body is disrupted as a result of the predominance of the tone of one of the parts of the autonomic nervous system. Vagotonic crises are, for example, bronchial asthma, urticaria, Quincke's edema, vasomotor rhinitis, motion sickness, sympathicotonic - vascular spasms in the form of symmetrical acroasphyxia, migraine, intermittent claudication, Raynaud's disease, transient form of hypertension, cardiovascular crises with hypothalamic syndrome, ganglion lesions.

Methods for studying the autonomic nervous system

The study of autonomic innervation is based, first of all, on assessing the state and function of the corresponding organs and systems. There are many clinical and laboratory methods for studying the autonomic nervous system. The choice of methodology is determined in accordance with the task and conditions of the study. However, in all cases it is necessary to take into account the initial state of autonomic tone. The study is best carried out in the morning on an empty stomach or 2 hours after meals, at the same time, at least 3 times. In this case, the minimum value of the obtained data is taken as the initial value.

Clinical, clinical-physiological and biochemical research methods are of great practical value and application.

The largest group consists cutaneous autonomic reflexes And samples.

Local dermographism– a reaction of the skin capillaries in the form of redness of the skin, which is caused by applying pressure with the handle of a hammer. Most often, a red stripe appears at the site of irritation; its width depends on the state of the autonomic nervous system. Of particular importance is too long (persistent) dermographism; this can be assessed as a predominance of excitability of skin vasodilators.

An even more convincing sign of such excitability (parasympathetic) is elevated dermographism, when after a stroke a swollen ridge of skin is formed. A manifestation of increased vasoconstrictor excitability (sympathetic) is white dermographism (spasm). The nature of local dermographism depends on the degree of pressure during streak stimulation and on the area of the skin surface. For example, weak irritations usually cause only white dermographism. It is especially pronounced on the skin of the lower extremities. The reaction of local dermographism can only be used to determine the tone of the sympathetic or parasympathetic part of the autonomic nervous system.

How does the autonomic nervous system affect the body? Reflex dermographism caused by irritation with a sharp object (drawn across the skin with the tip of a pin or needle). Reflex arc Such dermographism is closed in the segmental apparatus of the spinal cord. Some time after the impact, a strip appears with scalloped, uneven edges of varying widths, which lasts for several seconds. Reflex dermographism disappears with lesions of the dorsal roots of the spinal cord, as well as the anterior roots and spinal nerves at the level of the lesion. Above and below the innervation zone, the reflex is usually preserved. The so-called mustard test may also be recommended: thinly cut strips of mustard plasters are applied in a long narrow strip from top to bottom within the expected level of the lesion: the changes correspond to the indications of reflex dermographism (but this is not always accurate).

Pilomotor (piloarrector) reflexes skin are caused by pinching or cold (ice, ether) skin irritations, most often in the back of the head. “Goose bumps” (spinal reflex) should be considered a sympathetic reflex. Piloarrection, especially in a cold room, occurs normally. Pilomotor reflexes may have topodiagnostic value. With transverse lesions of the spinal cord, pilomotor reflexes, when stimulated at the top, do not extend below the zone of preservation of the segments (thus the upper limit of the lesion can be determined); with irritation below (in the area below the lesion), piloarrection extends upward only to the affected segments (i.e., the lower border of the lesion can be determined). In the area of the affected segments of the spinal cord themselves, the pilomotor reflex is absent.

Both dermographism and piloarrection do not always accurately determine the boundaries of the lesion.

Sweat reflexes skin are of great diagnostic value. Sweat glands have only sympathetic innervation. The mechanism of sweating is different. Disturbances in the sweating reflex can occur in various localizations of the disease process.

Aspirin test(with a glass of hot tea they give 1.0 g acetylsalicylic acid) causes diffuse sweating. At cortical lesions A monoplegic type of absence or decrease in sweating occurs; with damage to the diencephalic, hypothalamic region, a hemiplegic type occurs.

Warming the test subject causes spinal sweat reflexes (through cells of the lateral horns of the spinal cord). If the segmental centers of the spinal cord are affected, warming the patient, as well as an aspirin test, establishes the absence or decrease in sweating in the corresponding areas.

Test with pilocarpine(1 ml of a 1% solution of pilocarpine hydrochloride is administered subcutaneously to the patient). The absence or decrease in sweating indicates damage to the peripheral nervous system.

The best way determining sweating and areas of its disturbance is Minor's method. The patient's skin is covered with a solution of iodine mixed with alcohol and castor oil. Some time after drying, the skin is evenly sprinkled with starch powder. Then different ways sweating is caused, as a result of the combination of iodine with starch, an intense blue-violet, sometimes even black color is formed in the sweating areas. In those areas where sweating has not occurred, staining does not form. The results are photographed or sketched.

Another method for determining skin sweating (moisture) is electrometric. With this method, the fairly common apparatus of N. I. Mishchuk is used. With this method, it is more difficult to determine areas of impaired sweating.

Interesting, but difficult and difficult to evaluate the results obtained is electrodermal resistance method. The electrical conductivity of the skin is determined by a number of factors: humidity, i.e. sweating of the skin, condition of blood vessels, degree of hydrophilicity of the skin, etc. An increase in electrocutaneous resistance should be considered as a manifestation of the predominance of sympathetic innervation tone in the skin area under study.

Among skin tests, the study is widespread skin temperature. This sample has special meaning in a general assessment of visceral innervation, tone and its stability. The constancy of temperature is ensured by the regulating influence of cerebral visceral centers. In addition to mercury thermometers specially adapted for quick and accurate measurement of skin temperature of any areas of the skin, recently the electrometric method (thermocouple) is increasingly used, which is provided by N. N. Mishchuk’s device (combined apparatus PK-5).

Skin temperature reflects the state of the blood supply to the skin, which is important indicator autonomic innervation. Asymmetries of skin temperature (such as hemisyndrome) exceeding 1°C are observed with unilateral lesions of the hypothalamic region. There are territorial changes in temperature with focal lesions of the cerebral cortex - cerebral hemiplegia.

TO skin tests also applies to the definition skin sensitivity to ultraviolet rays by determining the biodose, i.e. establishing the minimum degree of exposure to rays at which redness occurs.

To ensure the standard, apply constant conditions irradiation. As a control, the results of irradiation under the same conditions of a symmetrical, “healthy” area are usually taken into account. Redness occurs through a reflex mechanism: histamine or histamine-like substances are formed in the skin during irradiation. Early onset and intensity of redness is regarded as a parasympathetic effect, delayed onset, weak intensity of erythema (redness) is regarded as sympathetic. This method is widely used for topical diagnostics: very clear data are obtained on the lesion peripheral nerves; asymmetries occur with cerebral hemiplegia, diencephalic and spinal lesions.

For research hydrophilicity skin, 0.2 ml of physiological solution is injected intradermally and the time of resorption of the resulting papule is taken into account. On various areas skin, the speed of resorption varies. On average it is 50–90 minutes. This test is highly sensitive (as is electrodermal resistance); using the results of this test to assess the general condition and damage to the nervous system requires caution, since the hydrophilicity of tissues changes significantly, for example, during feverish conditions, edema, cardiovascular disorders, etc.

Skin tests include the study of local reactions to sympathicotropic And vagotropic substances. Sympathicotropic drugs include adrenaline (administered in a solution of 1: 1000 in an amount of 0.1 ml intradermally). A spot of blanching and piloarrection appears at the injection site within 5-10 minutes (“ goose pimples"), which is surrounded by a red border of varying size and intensity. If the reaction is severe and lasting, it is concluded that sympathetic effect.

Acetylcholine is used as a vagotropic (parasympathicotropic) substance (0.1 ml of a 1: 10,000 solution is injected intradermally). A pale papule with a reddish border appears at the injection site; after some time, the area of redness increases to a maximum and after 15–25 minutes completely disappears. Greater intensity of the reaction is regarded as a parasympathetic effect.

The study has become quite widespread in clinical practice. cardiovascular reflexes.

Oculocardial reflex– the subject lies on his back in a free position, after some time his pulse is counted. After this, pressure is applied, preferably on both eyeballs simultaneously with the thumb and forefinger. It is recommended to apply pressure not on the anterior chamber, but on the lateral parts of the eyeball, and it should be quite intense, but not painful. After 20–30 s, without stopping the pressure, count the pulse for 20–30 s. The pulse rate before and after pressure is compared. Normally, the pulse slows down slightly (up to 10 beats). Large deceleration is regarded as a vagotonic effect, absence of deceleration or paradoxical acceleration - as sympathicotonic.

Neck reflex caused by pressure thumb to the area anterior to the sternocleidomastoid muscle, at the level of its upper third, below the angle of the lower jaw - until the pulsation of the carotid artery is felt. Normally, the heart rate slows down by 6-12 beats per minute. A high degree of deceleration, as well as changes in breathing, intestinal peristalsis and other signs, are regarded as a manifestation of increased tone of the vagus nerve system.

Epigastric (solar node) reflex called when the subject is positioned on his back with the abdominal muscles as relaxed as possible; measure blood pressure and pulse. Using your fingers, apply pressure to the area between the xiphoid process and the navel, gradually increasing the pressure until you feel a clear pulsation of the abdominal aorta. As a result, the heart rate slows and blood pressure decreases; the sharp degree of these reflex phenomena is regarded as an indicator increased excitability parasympathetic department. Sometimes reflexes of the sympathetic order also occur simultaneously - dilation of the pupils, etc. This is explained by the presence of both sympathetic and parasympathetic innervation in the solar plexus.

How does the autonomic nervous system affect the body?

When studying the autonomic nervous system, various hormonal studies are carried out due to the possibility of developing neuroendocrine disorders. A number of studies are also being conducted to determine the emotional and personal characteristics of a person to determine his mental state.

A detailed study of changes in autonomic innervation in diseases of internal organs can help in making an accurate diagnosis and determine the area for the use of reflex therapy.

Dysfunctions of the autonomic nervous system are usually present in the clinic of every disease of the nervous system. But there are diseases in which autonomic disorders turn out to be leading. They are caused by damage to the autonomic formations of the nervous system. The forms of diseases are distinguished depending on the level of damage to the autonomic nervous system.