肾交感神经射频消融术治疗顽固性高血压的护理

<正>顽固性高血压定义为在排除继发性高血压后,经使用包括利尿剂在内的、足量且合理的3种或以上降压药物治疗,血压仍未达标或者需至少4种降压药物方可控制血压[1]。我国成人高血压患者约有1.6亿,其中15%~20%为顽固性高血压,我国顽固性高血压病患者有3 000~4 000万[2]。我院2013年2月开始采用经皮穿刺肾动脉交感神经导管射频消融术(catheter-based renal denervation,RDN)治疗顽固性高血压,     

20例顽固性高血压患者肾交感神经射频消融术治疗的护理

顽固性高血压病是指在改善生活方式的基础上,应用了足量且合理联合的3种降压药物(包括利尿剂)后,血压仍在目标水平之上;或至少需要4种降压药物才能使血压达标,占高血压人群的15%～20%[1]。这使得专家学者在竭力研发新药物的同时,更加关注非药物治疗。2009年,澳大利亚Monash大学的Krum教授首次报告将肾交感神经射频消融术(renal sympathetic denervation,RSD)应用于顽固性高血压的治疗,开创了原发性高血压非药物治疗的新途径。我院心     

经皮肾动脉去交感神经术治疗难治性高血压病例随访及适应证选择探讨

经皮肾动脉去交感神经术是近年来治疗难治性高血压的重大突破之一.据统计,目前仍有约50％的高血压患者血压控制并未达标.而在血压没有能够达标的患者中,部分患者尽管应用了3种或3种以上足量(或最大量)的降压药物(其中一种为利尿剂),血压仍然无法达到目标值,称为难治性高血压(resistant hypertension)[1-2].研究表明难治性高血压患者可能占全部高血压患者的20％～30％.肾交感神经自T10至L1椎体发出,包绕于肾动脉外膜一直走行至肾脏.     

肾神经消融术治疗难治性高血压:现实与展望

难治性高血压是指在改善生活方式的基础上,应用了合理且剂量足够的3种降压药物(包括利尿剂)后,血压仍在目标水平之上,或至少需要4种药物才能使血压达标,此类患者占高血压的15%～20%。     

中医药治疗顽固性高血压研究进展

顽固性高血压（Resistant hypertension,RH）又称难治性高血压或高血压抵抗,是指在改善生活方式的基础上,应用了合理可耐受的足量3种或3种以上降压药物（包括利尿剂）1个月以上血压仍未达标,或服用4种或4种以上降压药物血压才能有效控制,称之为顽固性高血压[1]。随着社会发展,人们工作节奏的加快,生活水平的提高,肥胖人群的增多以及社会人口老龄化的加剧,RH的发病有较为严重的上升趋势。     

经导管射频消融去肾神经治疗高血压:当前问题与展望

<正>高血压作为最常见的慢性疾病之一,估计目前在全球范围内的成人患病率约达26.4%,预计到2025年会上升到29.2%[1]。由于高血压会引发一系列严重的心血管临床事件,因此降压达标非常重要。顽固性高血压定义为,在改善生活方式的基础上,合理联合应用了3种或以上的足量降压药物(包括利尿剂)治疗1个月以上,血压仍未达标,或服用4种或以上的降压药物血压才能达标。据估计,     

难治性高血压合并糖尿病1例的护理

难治性高血压(resistant hypertension,RH)又称抵抗性高血压或顽固性高血压,是指对高血压患者实施包括调整生活方式及应用至少3种或以上足量降压药后血压仍不能达正常参考值[1]。糖尿病是心脑血管疾病最重要的因素之一。持久的高血压和高血糖将增加患者脑卒中、心肌梗死、     

顽固性高血压的临床诊治研究

顽同性高血压又称为难治性高血压,一般指高血压患者应用调整生活方式和服用3种或3种以上包括利尿药在内不同作用机制的全剂量降压药物,诊所偶测血压仍不能控制在目标血压水平(SBP<140 mmHg和DBP<90 mmHg,糖尿病或肾病患者应<130/80 mmHg)者.本文对顽吲性高血压的临床诊治研究进行总结,以期为临床顽固性高血压的诊断与治疗提供参考.     

经皮肾动脉交感神经消融术治疗顽固性高血压1例围术期护理

目的:探讨经皮肾动脉交感神经消融术(RDN)治疗顽固性高血压患者的围术期护理方法及效果。方法:对RDN患者加强术前心理、常规检查、用药护理、饮食护理;术中做好手术器械、药品准备,并对特殊问题加强防范工作;术后给予用药、肢体血运、血压监测指导;重视出院指导和随访工作。结果:RDN治疗顽固性高血压行之有效且安全,具有比较显著且持久的降压作用。结论:做好RDN围术期护理和加强术中问题观察及处理,重视出院指导和随访工作是治疗成功的保证。     

Meta分析对肾去交感神经术治疗顽固性高血压试验的再评价

目的：利用 Meta 分析方法可合并同质研究提高检验效能的特点,对肾去交感神经术治疗顽固性高血压的临床试验结果进行再评价。方法对纳入的 Symplicity HNT-1、Symplicity HNT-1补充、Symplicity HNT-2、Catheter-based RSD临床随机对照试验,依据GRADE系统推荐分级方法,进行质量评价,运用Review Manager对选定的随机试验进Meta分析。结果 Meta分析的两个终点的结果显示：肾去交感神经术治疗优于单纯药物治疗,其差异具有统计学意义,OR（95%CI）分别为14.83（6.63,32.20）、3.45（1.18,10.08）。GRADE系统推荐分级显示：以术后降压药物剂量和（或）种类减少为事件终点,四项试验证据等级均为低级;以术后6个月患者收缩压血压值为终点,Symplicity HNT-1试验、Catheter-based RSD试验证据等级为中级,Symplicity HNT-1补充试验、Symplicity HNT-2试验证据等级为低级。结论以收缩压降低10 mm Hg为疗效标准,肾去交感神经术治疗顽固性高血压优于单纯药物治疗,且无严重并发症及后遗症。鉴于纳入研究少、样本含量低,仍需开展大样本、多中心、科学规范的临床随机对照试验,以全面评价肾去交感神经术的安全性与有效性。     

Effects of renal denervation on insulin resistance

Hypertension and diabetes are recognized as two major comorbidities accounting for the greatest proportion of cardiovascular morbidity and mortality. Despite the availability of safe and effective pharmacological therapies, the percentage of patients achieving optimal blood pressure and glycemic control remains unsatisfactory. The contribution of sympathetic activation to the development and maintenance of systemic hypertension and comorbidities is well recognized. Aside from several novel pharmacological approaches, catheter-based sympathetic renal denervation (RDN) has gained a significant role in treatment-resistant hypertension and has recently been introduced to clinical practice. Preliminary data indicate that aside from better blood pressure control, RDN may also be associated with a reduction in fasting glucose and insulin levels, as well as improvements in the Homeostasis Model Assessment (HOMA) index. If these observations are confirmed in larger controlled clinical trials, RDN may emerge as a preferred treatment option for patients with resistant hypertension and concomitant alterations of glucose metabolism.     

Renal denervation: effects on atrial electrophysiology and arrhythmias

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and mortality. Currently, atrial endocardial catheter ablation, mainly targeting focal discharges in the pulmonary veins, is the most widely used interventional treatment of drug-refractory AF. Despite technical improvements, results are not yet optimal. There is ongoing search for alternative and/or complementary interventional targets. Conditions associated with increased sympathetic activation such as hypertension, heart failure and sleep apnea lead to structural, neural and electrophysiological changes in the atrium thereby contributing to the progression from paroxysmal to persistent AF and increasing recurrence rate of AF after PVI. Until now, interventional modulation of autonomic nervous system was limited by highly invasive techniques. Catheter-based renal denervation (RDN) was introduced as a minimally invasive approach to reduce renal and whole body sympathetic activation with accompanying blood pressure control and left-ventricular morphological and functional changes in resistant hypertension. This review focuses on the potential atrial antiarrhythmic and antiremodeling effects of RDN in AF patients with hypertension, heart failure, and sleep apnea and discusses the possible role of RDN in the treatment of AF.     

Renal sympathetic denervation for treatment of electrical storm: first-in-man experience

Introduction  

Sympathetic activity plays an important role in the pathogenesis of ventricular tachyarrhythmia. Catheter-based renal sympathetic denervation (RDN) is a novel treatment option for patients with resistant hypertension, proved to reduce local and whole-body sympathetic activity.     

Computed tomography-guided chemical renal sympathetic nerve modulation in the treatment of resistant hypertension: A case report

BACKGROUNDResistant hypertension (RH) has always been a difficult problem in clinical diagnosis and treatment. At present, there is no recognized safe and effective minimally invasive treatment.CASE SUMMARYAn 80-year-old woman was admitted to hospital due to trigeminal neuralgia (TN). The patient had a history of RH for more than 10 years and her blood pressure (BP) was not well-controlled. Before the treatment for TN, we decided to perform chemical renal sympathetic denervation with ethanol in the Pain Department of our hospital. One year after the operation, she stopped taking antihypertensive drugs, and her BP was satisfactorily controlled within 4 years after surgery. CONCLUSIONComputed tomography-guided chemical renal sympathetic modulation may be a feasible method for the treatment of RH.     

Renal sympathetic denervation therapy in the real world: results from the Heidelberg registry

Introduction

Renal sympathetic denervation (RDN) is a novel treatment option in patients with treatment-resistant arterial hypertension. A subset of recently published randomized and non-randomized trials indicates that RDN leads to sustained lowering of blood pressure (BP) under controlled study conditions. However, registry data that allow evaluation of safety and efficacy in a real-world setting are largely missing.

Methods

Sixty-three consecutive patients with treatment-resistant hypertension underwent RDN with the radiofrequency-based Symplicity? catheter. As part of our prospective registry, treatment efficacy and safety were monitored after 3, 6, and 12 months.

Results

At 6 months follow-up, office systolic BP significantly improved by 19 + 23 mmHg as compared to baseline, while diastolic BP values reduced by 6 + 13 mmHg (p < 0.05). One year after RDN, office BP levels further improved (26 + 25 mmHg in systolic BP and 9 + 13 mmHg in diastolic BP, respectively), even though 19 patients had reduced the number and/or dosage of antihypertensive agents. The response rate, defined as reduction of office systolic BP of ≥10 mmHg, was 73 % after 6 months. Baseline BP was the only significant predictor of blood pressure response, whereas no correlation was found between the number of ablation points and the individual changes in office blood pressure. Interestingly, patients with challenging renal anatomy profited somewhat less from the procedure than those with “normal” renal anatomy. Procedure related adverse events occurred in three patients (4.7 %) and were limited to vascular access complications.

Conclusions

RDN with the Symplicity? system is safe and effective in patients with treatment-resistant hypertension also in a real-world setting.     

Effect of Catheter-Based Renal Denervation on Uncontrolled Hypertension: A Systematic Review and Meta-analysis

ObjectiveTo assess the efficacy and safety of catheter-based renal denervation (RDN) for the treatment of uncontrolled hypertension by conducting a systematic review and a meta-analysis.MethodsThe Medline, Cochrane Library, and Embase databases were searched for clinical studies between January 1, 2009, and July 16, 2018. Studies that evaluated the effect of RDN on uncontrolled hypertension were identified. The primary endpoints were changes in 24-hour ambulatory systolic blood pressure (BP) and office systolic BP. The secondary endpoints included changes in 24-hour ambulatory diastolic BP, office diastolic BP, and major adverse events.ResultsAfter a literature search and detailed evaluation, 12 randomized controlled trials with a total of 1539 individuals were included in the quantitative analysis. Pooled analyses indicated that RDN was associated with a significantly greater reduction of 24-hour systolic BP (mean difference [MD], ?4.02 mm Hg; 95% CI, ?5.49 to ?2.56; P<.001) and office systolic BP (MD, ?8.93 mm Hg; 95% CI, ?14.03 to ?3.83; P<.001) than controls. Similarly, RDN significantly reduced 24-hour diastolic BP (MD, ?2.05 mm Hg; 95% CI, ?3.05 to ?1.05; P<.001) and office diastolic BP (MD, ?4.49 mm Hg; 95% CI, ?6.46 to ?2.52; P<.001). RDN was not associated with an increased risk of major adverse events (relative risk, 1.06; 95% CI, 0.72 to 1.57; P=.76).ConclusionsCatheter-based RDN was associated with a significant BP-lowering benefit without increasing major adverse events.     

Out with the old,in with the new: an updated risk stratification equation for pulmonary arterial hypertension

The Symplicity studies suggest that intravascular renal sympathetic nervous denervation improves blood pressure in patients with resistant hypertension, thus potentially opening a market for devices to be used when conventional drug therapy fails to restore blood pressure control. However, the size and durability of the antihypertensive, renal and sympatholytic effects of renal denervation, the long-term safety, improvement of quality of life, the possibility to relax antihypertensive drug treatment, the cost-effectiveness, and long-term hard cardiovascular-renal outcomes still remain to be firmly established. Most ongoing studies are small, industry-driven and purely observational with objectives to test new catheters and source of energy for renal nerve ablation or to search for ancillary benefits and new indications of the technique. The most urgent need, that is adequately powered randomized clinical trials testing renal denervation versus usual medical therapy delivered according to the state-of-the-art are under-represented and seldom funded by industry. The authors make a plea for a coordinated research effort in Europe. With this objective, they established collaboration with leading European experts and started the European Network for Coordinating Research on Renal Denervation. In the meantime, renal denervation should remain the ultima ratio in adherent and truly resistant patients with severe hypertension, confirmed by ambulatory monitoring, in whom secondary hypertension has been excluded and in whom all other efforts to reduce blood pressure have failed.     

Ambulatory blood pressure monitoring in the diagnostics of arterial hypertension associated with nephroptosis

Nephroptosis, associated with renal circulatory disorder, is one of the reasons for symptomatic arterial hypertension (AH). An obvious dependence of blood pressure (BP) level on the body position is a feature of this form of AH. However, this correlation is not always easy to reveal when performing a routine physical examination. The authors of the article adduce 2 clinical observations in which ambulatory BP monitoring became the key method that allowed assuming dynamic vasorenal AH.     

Hypertension alone or related to the metabolic syndrome in postmenopausal women

Hypertension treatment and control efforts represent a major component of primary care with dedicated clinical guidelines and recommendations. However, high blood pressure (BP) control rates are complicated with the difficult to treat and resistant hypertensive patients. This category of patient, therefore, affects the development and implementation of the clinical guidelines. The recommendations of specific algorithms for resistant hypertension and difficult-to-treat patients with elevated BPs have been developed in consideration of new therapies and combination drug treatment. Hypertension treatment guidelines include and will continue to grade evidence from randomized clinical trials with detailed strategies on the management of these high-risk patients. Although resistant hypertension affects high BP control rates, the inclusion of refined pharmaceutical and device treatment strategies in evidence-based guidelines will be expected to have a significant impact on the clinical management of this high-risk patient population.     

诊室血压、动态血压及家庭血压测量对于高血压患者诊断和管理的研究进展

目的比较诊室血压测量(OBPM)、动态血压测量(ABPM)及家庭血压测量(HBPM)在高血压患者诊断和管理等方面的异同性,得出最优血压识别和管理模式。方法对OBPM、ABPM和HBPM在高血压患者诊断中的性价比、对靶器官损害的预测意义、预测慢性肾脏病(CKD)患者的不良结局和进展及血压变异性(BPV)等不同方面进行比较。结果与OBPM相比,ABPM在初步诊断高血压上性价比最高,HBPM在高血压患者的长期自我管理方面性价比最优。在高血压人群中,HBPM和ABPM在预测心血管事件、脑卒中、终末期肾脏病及全因死亡率等不良结局方面比OBPM有着更高的临床价值,且HBPM在临床实践中更有优势。对于肾功能不全的高血压患者,将ABPM和HBPM所得血压值控制在目标范围之内,有利于延缓患者肾功能不全的进展,降低其心血管事件的发生风险,并且减少患者长期透析治疗的需要,其中ABPM更胜一筹。OBPM、ABPM和HBPM得出的BPV都具有预测心血管事件的意义,然而HBPM表现更为突出。结论与OBPM相比,ABPM在初步诊断高血压及CKD患者的血压控制上最优;HBPM在预测靶器官损害、评估BPV及高血压的长期管理中临床实际运用价值最高。