顽固性高血压原因分析及治疗对策

报告104例顽固性高血压患者,主要原因为顺从性不好32例,重视并发症治疗而忽视降压治疗31例,继发性高血压11例,合并症急性发作时药物互相拮抗8例,单纯高血压未注意生活干预22例.其治疗原则是在生活干预基础上调整并联用降压药物,其中利尿剂 血管紧张素转化酶抑制剂(ACEI) 钙离子拮抗剂(CCB)68例,利尿剂 CCB β受体拮抗剂(βRB)13例,CCB βRB 血管紧张素Ⅱ受体拮抗剂(ARB)10例,利尿剂 ACEI CCB βRB13例.结果经调整降压药物治疗后,血压降至正常96例,控制不理想8例.提示分析顽固性高血压原因,在生活干预基础上去除诱发因素,调整降压治疗方案,足量联用降压药物,可有效控制顽固性高血压.     

高龄男性原发性高血压患者降压药物应用现状

目的探讨高龄男性原发性高血压患者的降压药物治疗现状,为临床治疗提供参考。方法对106例75岁以上男性原发性高血压患者出院时降压药物应用方案进行登记并行χ2检验。结果应用最多的是长效钙离子拮抗剂(CCB,77.35%)、其次是β受体阻滞剂(46.23%)、血管紧张素转换酶抑制剂(40.57%)、血管紧张素Ⅱ受体拮抗剂(28.30%)、利尿剂(26.42%)和α受体阻滞剂(0.94%),长效CCB明显高于其他种类降压药物,有78.31%的患者需要两种以上降压药物的联合治疗,平均服降压药物种类(2.19±0.86)种例。结论高龄男性原发性高血压患者适用于以长效CCB为基础的小剂量联合降压治疗方案,而利尿剂不是其一线药物。     

高龄老人高血压的治疗现状及体位改变的相关因素

目的探讨高龄老人高血压的治疗现状及体位改变的相关因素。方法选择2015年1~7月高龄老人2 000例进行问卷调查,观察患者降压药物使用情况、随访血压情况、影响降压治疗的因素以及体位性低血压(OH)和体位性高血压(OHT)与心血管疾病的关系。结果高龄老人高血压患者使用的降压药物包括:钙拮抗剂(54.73%)、血管紧张素转换酶抑制(16.25%)、血管紧张素受体抑制剂(17.04%)、利尿剂(6.82%)、β受体阻滞剂(3.54%)和其他药物(1.62%)。患者血压测量主要在医院/医疗机构测量(51.07%)和家庭自测(36.14%)。大多数患者坚持每天、每月血压测量(96.82%),部分患者每年一次或者从不进行血压监测(3.18%)。908例高龄高血压患者中,诊断为OH者298例(32.82%),OHT者171例(18.83%)。OH组、OHT组患者冠心病、高脂血症、糖尿病和脑卒中的患病率均高于非OH/OHT组(P0.05)。结论高龄老人高血压的治疗药物中,钙拮抗剂、肾素血管紧张素系统阻断剂得到广泛认同,而利尿剂的使用相对不足,患者自我管理模式的实行有待加强,冠心病、高脂血症、糖尿病、脑卒中均与体位改变有关。     

57例糖尿病合并高血压患者降压治疗临床分析

目的探讨糖尿病合并高血压患者降压治疗情况。方法将57例糖尿病合并高血压患者从性别、发病年龄、家族史、病程、并发症、高血压级别、药物治疗等方面进行分析。结果应用血管紧张素转换酶抑制剂(ACEI)20例,钙离子拮抗剂(CCB)25例,β受体阻滞剂10例,血管紧张素Ⅱ受体拮抗剂(ARB)37例,利尿剂5例;单一用药11例,联合用药46例。结论糖尿病合并高血压者,应尤先考虑血管紧张素转换酶抑制剂或血管紧张素Ⅱ受体拮抗剂,血压控制不满意,渐加用钙离子拮抗剂、β受体阻滞剂、利尿剂,将血压控制达标,延缓并发症的发生。     

老年高血压的治疗策略

高血压是老年人群中的常见疾病,目前老年高血压已成为重要的公共卫生问题。老年高血压的治疗策略主要为：在改善生活方式等非药物治疗措施的基础上,选择合适的降压药物治疗使血压达标。常用的五类降压药物,噻嗪类利尿剂、钙通道拮抗剂、血管紧张素转换酶抑制剂、血管紧张素受体阻滞剂、β受体阻滞剂均可作为一线降压药物用于老年高血压的起始和维持治疗、单药或优化联合治疗。老年人降压治疗应遵循个体化原则,宜平稳、缓慢,降压药物起始剂量要小,逐渐增加剂量。治疗过程中须注意监测药物不良反应和其他心血管危险因素及合并疾病的治疗,并长期坚持治疗。     

高血压的降压药物治疗——从ALLHAT临床试验得到的启迪

高血压降压药物治疗已取得重要进展 ,传统的降压药物噻嗪类利尿剂和 β阻滞剂降压治疗的受益早已得到确认。近年来 ,一些新的降压药例如血管紧张素转换酶抑制剂 (ACEI)、钙拮抗剂 (CCB)、α受体阻滞剂及血管紧张素受体拮抗剂 (ARB)又相继应用于临床 ,ACEI和CCB与安慰剂的随机双盲对照试验已证实其在高血压患者可降低心血管事件 ,但这些新的药物是否比价格明显低廉的传统药物具有更多的优越性尚不明了。2 0 0 2年 12月在JAMA杂志发表的“降血压和降血脂预防心肌梗死临床试验 (anti hypertensiveandlipidloweringtopreventheartattac…     

血管紧张素受体拮抗剂治疗高血压

肾素-血管紧张素-醛固酮系统（RAAS）是调节血压的主要机制,也是治疗高血压病的重要靶点。血管紧张素受体拮抗剂（ARBs）,通过阻滞特异性血管紧张素受体,干扰RAAS的活性,成为治疗高血压的一线药物。临床结果显示ARBs作为单用药或联合其他降压药物治疗高血压有其特殊的优势。在降压方面,与血管紧张素转换酶抑制剂和其他类型的降压药物相比,ARBs具有良好的耐受性而适合用于治疗更广泛的患者。最近研究结果显示在12个月期间使用ARBs治疗高血压依从性明显高于其他降压药物,而且副作用少。具备临床有效性和良好耐受性的ARBs药物,可以作为治疗高血压的主要药物。     

植入式压力反射刺激装置治疗顽固性高血压的研究进展

高血压患者使用了3种或3种以上的降压药物包括利尿剂在内而难以使血压得到有效的控制,称为顽固性高血压.血压的调节涉及多种因素,主要为内皮功能、自主神经、肾素-血管紧张素系统三种调节系统.药物虽能作用于各调节系统,但对于顽固性高血压患者疗效却有限,近年来有两种新技术用于抗交感神经治疗顽固性高血压,即肾动脉交感神经射频消融术和植入式压力反射刺激装置,现就后者作一综述.     

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盐敏感性高血压是基因机制、离子转运机制、内皮功能障碍机制、肾脏机制、交感神经系统和中枢神经系统机制、肾素-血管紧张素-醛固酮机制、内分泌机制、胰岛素抵抗机制等等共同作用的结果。除了限盐治疗以外,其他针对盐敏感性高血压的降压措施包括补充钾离子和钙离子,降压药治疗,免疫疗法,基因疗法等等。降压药物包括利尿剂、钙离子拮抗剂、血管紧张素转化酶抑制剂、血管紧张素受体拮抗剂都是治疗盐敏感性高血压的适用药物,改变我国高盐饮食习惯是盐敏感性高血压一级预防的关键性措施。     

抗高血压药物的选择

国内外几个重要的高血压治疗指南(指南)将利尿剂、β-受体阻滞剂、钙通道阻滞剂(CCB)、血管紧张素转换酶抑制剂(ACEI)、血管紧张素Ⅱ受体拮抗剂(ARB)以及α-受体阻滞剂作为一线抗高血压药物。六大类抗高血压药物的广泛应用，使高血压治疗及控制状况得到改观，大大降低了全球心血管病发生和死亡的危险。但目前如何正确选择及合理使用抗高血压药物，更大程度地使高血压患者从抗高血压药物治疗中获益，是我们今后面临的重要任务之一。     

Hypertension prevalence and control in Ulaanbaatar,Mongolia

This study examines the prevalence, awareness, treatment, and control of hypertension in Ulaanbaatar, Mongolia, using both the American Heart Association and conventional thresholds (130/80 and 140/90 mm Hg, respectively). In this randomized cross‐sectional study, two‐stage cluster sampling was used to obtain a sample of 4515 individuals aged ≥20 years. Hypertension was defined by the use of antihypertensives in the last 2 weeks or a blood pressure at or above the thresholds of 140/90 and 130/80 mm Hg. The mean age of the participants was 41.1 ± 14.0 years and 54.5% were women. Hypertension prevalence was 25.6% (using 140/90 mm Hg) and 46.5% (using 130/80 mm Hg). Prevalence increased with age and below 50 years men were consistently more likely to be hypertensive. Among hypertensive participants, the rates of awareness, treatment, and control were 69.7%, 46.8%, and 24.0% (using 140/90 mm Hg) and 49.1%, 25.8%, and 6.4% (using 130/80 mm Hg, respectively). Men had lower rates of awareness, treatment, and control compared with women, with the most pronounced differences at younger ages. This study shows that awareness, treatment, and control rates in Ulaanbaatar are better than in most low‐ and middle‐income countries but are still suboptimal. The largest “care gap” was in young men where a regulatory requirement for annual workplace blood pressure screening has the potential to enhance care. A major hypertension control program has just been initiated in Ulaanbaatar.     

Redefining primary hyperaldosteronism as “The Syndrome of Inappropriate Aldosterone Secretion (SIALDS)”: A common but unrecognized cause of hypertension

The current screening and diagnostic recommendations for detecting Primary Hyperaldosteronism (PHA) focus on diagnosing the more severe and overt instances of renin-independent aldosterone production. However, milder forms of autonomous aldosterone secretion have been demonstrated to exist below the diagnostic thresholds of current PHA guidelines, and associate with clinically relevant cardiovascular risk. PHAencompasses a spectrum of renin independent aldosterone production, progressing from a subclinical state in normotensives to a full-blown clinical syndrome representing the resistant hypertension population. The authors propose the Syndrome of Inappropriately Elevated Aldosterone Secretion (SIALDS) concept as a potential new paradigm for understanding and diagnosing PHA and expanded diagnostic approach to improve early detection even in well-controlled hypertension. The authors also delve into the impact of treatments, including mineralocorticoid receptor antagonists and emerging aldosterone synthase inhibitors. Furthermore, The authors outline future research directions, proposing clinical trials to investigate the long-term identification and treatment outcomes of SIALDS.     

Is tinnitus an early voice of masked hypertension? High masked hypertension rate in patients with tinnitus

Objectives: Tinnitus is hearing a sound without any external acoustic stimulus. There are some clues of hypertension can cause tinnitus in different ways. The aim of the study was to evaluate the relationship between tinnitus and masked hypertension including echocardiographic parameters and severity of tinnitus.

Methods: This study included 88 patients with tinnitus of at least 3 months duration and 85 age and gender-matched control subjects. Tinnitus severity index was used to classify the patients with tinnitus. After a complete medical history, all subjects underwent routine laboratory examination, office blood pressure measurement, hearing tests and ambulatory blood pressure monitoring. Masked hypertension is defined as normal office blood pressure measurement and high ambulatory blood pressure level.

Results: Baseline characteristics in patients and controls were similar. Prevalence of masked hypertension was significantly higher in patients with tinnitus than controls (18.2% vs 3.5%, p = 0.002). Office diastolic BP (76 ± 8.1 vs. 72.74 ± 8.68, p = 0.01), ambulatory 24-H diastolic BP (70.2 ± 9.6 vs. 66.9 ± 6.1, p = 0.07) and ambulatory daytime diastolic BP (73.7 ± 9.5 vs. 71.1 ± 6.2, p = 0.03) was significantly higher in patients with tinnitus than control group. Tinnitus severity index in patients without masked hypertension was 0 and tinnitus severity index in patients with masked hypertension were 2 (1–5).

Conclusion: This study demonstrated that masked hypertension must be kept in mind if there is a complaint of tinnitus without any other obvious reason.     

老年高血压病患者血液流变学分析

对48例老年高血压患者（合并冠心病21例，糖尿病10例）进行血液流变学测定。结果老年高血压组纤维蛋白原（Fg）、血浆粘度（ηP）与对照组比较，P＜0．01。全血粘度（ηb）、全血还原粘度（ηh）、血沉（ESR）、血小板粘附率（PAD）及体外血栓干重（DW）与对照组比较，P＜0．05；高血压合并冠心病组与单纯高血压组比较，ηb，ηh，PAD及体外血栓长度（L）、湿重（MW）（P＜0．05），DW（P＜0．01）；高血压合并糖尿病组与单纯高血压组比较，Fg（P＜0．01），ηh，ηh，ESR，PAD，L，DW，（P＜0．05）。结果提示，老年高血压病患者血液流变学改变表现为纤维蛋白原增高、红细胞刚性增加、红细胞变形能力降低，致红细胞聚集性增强。高血压合并冠心病或糖尿病组，均以血小板反应性增高、红细胞聚集性增强、内皮功能受损及体外血栓形成能力增强更为突出。     

Portopulmonary hypertension

Portopulmonary hypertension (PPHT) is defined as precapillary pulmonary hypertension accompanied by hepatic disease or portal hypertension. Pulmonary hypertension results from excessive pulmonary vascular remodeling and vasoconstriction. These histological alterations have been indistinguishable from those of other forms of pulmonary arterial hypertension. Factors involved in the pathogenesis of PPHT include volume overload, hyperdynamic circulation, and circulating vasoactive mediators. The disorder has a substantial impact on survival and requires focused treatment. Liver transplantation in patients with moderate to severe PPHT is associated with a significantly reduced survival rate. The best medical treatment for patients with PPHT is controversial; most authors currently regard continuous intravenous application of prostacyclin as the treatment of choice for patients with severe PPHT. There is only very limited reported experience with inhaled prostacyclin or its analog, iloprost. Increasing evidence of the efficacy of the endothelin-receptor antagonist bosentan and of the phosphodiesterase-5 inhibitor sildenafil is emerging in highly selected patients with PPHT. In the future, a combination therapy of the above-mentioned agents might become a therapeutic option. Other agents such as β-blockers seem to be harmful to patients with moderate to severe portopulmonary hypertension. Up-to-date, randomized, double-blind, controlled clinical trials are lacking and are needed urgently. An erratum to this article is available at .     

Relationship between Blood Pressure and Nocturia in Hypertensive Patients

Objective: We investigated the relationship between the pattern of hypertension and nocturia. Methods: Seventy‐seven patients who were being treated for hypertension completed a questionnaire regarding the number of times they urinated during the day and at night, and measured their blood pressure at home immediately after rising in the morning and just before going to sleep at night. The patients' blood pressure was also measured at the clinic. The patients were divided into groups according to their blood pressure patterns. The relationship between blood pressure pattern and number of urinations during the day and at night was investigated. Results: When the patients were divided into white coat hypertension, masked hypertension, sustained hypertension, and normotension groups, the number of daytime urinations was significantly lower in the sustained hypertension group compared with the normotension and white coat hypertension groups. When the subjects were divided into morning blood pressure surge and non‐morning surge groups or into morning hypertension and non‐morning hypertension groups, the numbers of nighttime urinations was significantly higher in the morning surge group or the morning hypertension group compared with the non‐morning surge group or non‐morning hypertension group, respectively. Conclusion: Sustained hypertension and elevation of blood pressure in the early morning influence the frequency of daytime and nighttime urination, respectively. It is important to control both the blood pressure and nocturia of hypertensive patients to improve their prognosis.     

Masked hypertensives: A disguised arterial stiffness population

The aim of this study was to determine whether masked hypertension (MHT) and white coat hypertension (WCHT) could be related to increased arterial stiffness and to identify the best office cutoff values of office BP for the diagnosis of MHT and WCHT. A total of 542 consecutive patients (50.2% male, age 42.5 ± 26.2 years) were included in the study. Patients were never treated before for hypertension. Patients were classified as true normotensives (44%), true hypertensives (30%), WC hypertensives (19%), and masked hypertensives (7%). Carotid‐femoral pulse wave velocity (c‐f PWV) was 9.91 ± 0.20 m/s in true normotension, 10.26 ± 0.27 m/s in WCHT, 11.28 ± 0.47 m/s in MHT, and 11.86 ± 0.23 m/s in true hypertension after adjustment for age and sex. Decision limits yielding 65% sensitivity were 130 mm Hg for office systolic BP with 72% specificity for the diagnosis of MHT. The optimal cutoff value of 80 mm Hg for office diastolic BP provides 60% sensitivity and 68% specificity. Decision limits yielding 63% sensitivity were 150 mm Hg for office systolic BP with 72% specificity for the diagnosis of WCHT. The optimal cutoff value of 95 mm Hg for office diastolic BP provides 75% sensitivity and 51% specificity. The presence of MHT should be taken into account when increased c‐f PWV is detected in the absence of office hypertension. The optimal office BP of 130/80 mm Hg provides the best sensitivity and specificity for the diagnosis of MHT. As regards the diagnosis of WCHT, the cutoff value of 150/95 mm Hg seems to provide the best option.     

Resistant hypertension, secondary hypertension, and hypertensive crises: diagnostic evaluation and treatment

Hypertension is a very common modifiable risk factor for cardiovascular morbidity and mortality. Patients with hypertension represent a diverse group. In addition to those with primary hypertension, there are patients whose hypertension is attributable to secondary causes, those with resistant hypertension, and patients who present with a hypertensive crisis. Secondary causes of hypertension account for less than 10% of cases of elevated blood pressure (BP), and screening for these causes is warranted if clinically indicated. Patients with resistant hypertension, whose BP remains uncontrolled in spite of use of 3 or more antihypertensive agents, are at increased cardiovascular risk compared with the general hypertensive population. After potentially correctible causes of uncontrolled BP (pseudoresistance, secondary causes, and intake of interfering substances) are eliminated, patients with true resistant hypertension are managed by encouraging therapeutic lifestyle changes and optimizing the antihypertensive regimen, whereby the clinician ensures that the medications are prescribed at optimal doses using drugs with complementary mechanisms of action, while adding an appropriate diuretic if there are no contraindications. Mineralocorticoid receptor antagonists are formidable add-on agents to the antihypertensive regimen, usually as a fourth drug, and are effective in reducing BP even in patients without biochemical evidence of aldosterone excess. In the setting of a hypertensive crisis, the BP has to be reduced within hours in the case of a hypertensive emergency (elevated BP with evidence of target organ damage) using parenteral agents, and within a few days if there is hypertensive urgency, using oral antihypertensive agents.