难治性高血压非药物治疗的某些进展

目前,尽管新的降压药物和复方制剂已经出现,但高血压的诊断和治疗,特别是难治性高血压的治疗仍不容乐观。近年来,不断涌现的高血压非药物治疗如肾脏去交感神经消融、颈动脉窦压力感受器以及压力支架等,在难治性高血压的治疗中取得了较为满意的疗效,为难治性高血压的治疗提供了新的思路和方法。本文就难治性高血压的非药物治疗作一综述。     

高血压的器械治疗:现状与展望

寻找有效、便携、一次治疗长期降压的非药物降压方法是难治性高血压治疗的众望所归之事。近十余年来,各种基于器械的降压疗法陆续出现,包括去肾交感神经术、压力感受器刺激疗法、颈动脉体消融术、髂动静脉造瘘等,本文就这些疗法的现状和发展前景进行了评述。     

经皮肾交感神经射频消融术治疗难治性高血压:附2例报告

目的初步观察和探索经皮肾交感神经射频消融术治疗难治性高血压的疗效及操作方法。方法对2例难治性高血压患者实施经皮肾交感神经射频消融术并随访半年至一年,观察其血压及用药水平的变化。结果术后患者的血压较术前明显下降,降压药物种类及剂量亦减少。随访结果显示2例患者的高血压药物使用剂量和种类均有减少,其中1例患者血压控制在目标水平,1例未达到目标水平。结论难治性高血压患者通过经皮肾交感神经射频消融术使血压持续下降,用药剂量和种类减少。     

去肾交感神经术治疗难治性高血压:现状与展望

正尽管抗高血压药物研究有进展,仍然有部分高血压患者的血压经规范的降压治疗无法达标,成为临床上棘手的难治性高血压(顽固性高血压)[1]。此类患者在服用3种降压药(其中一种是利尿药)至最大剂量或最大耐受后血压仍然得不到有效的控制。去肾交感神经术(renal denervation,RDN)是一种新兴技术,通过阻断肾交感神经,降低交感神经兴奋性而达到降压目的。多项临床研究显示这种技术有可能显著且安全地     

经导管射频消融去肾脏交感神经术治疗难治性高血压研究现状

经导管射频消融去肾脏交感神经术是一种治疗难治性高血压的新兴非药物手段,作为一种微创手术,可以选择性消融肾交感神经纤维,阻断中枢交感神经和肾脏之间神经冲动的传递,从而达到控制血压的目的。目前关于经导管射频消融去肾脏交感神经术治疗难治性高血压的研究较多,但具有一定的争议性,现就经导管射频消融去肾脏交感神经术治疗高血压开展的有关研究现状做一综述。     

导读

正高血压的器械治疗:现状与展望(邓宇,等p601)寻找有效、便携、一次治疗长期降压的非药物降压方法是难治性高血压治疗的众望所归之事。近十余年来,各种基于器械的降压疗法陆续出现,包括去肾交感神经术、压力感受器刺激疗法、颈动脉体消融术、髂动静脉造瘘等,本文就这些疗法的现状和发展前景进行了评述。阿司匹林在高血压患者心血管病一级预防中是否还有应用价值(郭艺芳,等p605)     

24h动态血压监测预测和评估经皮经导管射频消融去肾交感神经术的降压作用

<正>经皮经导管射频消融去肾交感神经术治疗难治性高血压(renal denervation for resistant hypertension,DENERHTN)临床试验显示,明确诊断的难治性高血压患者经英国指南推荐的标准化阶梯降压治疗(standardized stepped-care antihypertensive treatment,SSAHT)加上使用Symplicity导管的经皮经导管射频消融去肾交感神经术(renal denervation,RDN),随访     

肾动脉周围交感神经解剖分布情况的研究进展

<正>交感神经过度激活是高血压尤其是难治性高血压(resistant hypertension,RH)发生和维持的重要机制[1]。多项研究表明以肾交感神经为靶点的经皮经导管射频消融去肾交感神经术(renal denervation,RDN)能安全有效地降压[2-7]。然而现今的螺旋式消融却有一定盲目性,因导管可能在交感神经并不密集的区域无效消融,这也可能是术后无降压反应(术后半     

肾交感神经消融治疗难治性高血压的疗效与思考

虽然有多类化学药物用于高血压的治疗,但目前高血压的控制率仍很低,在未控制的高血压患者中,约30.0%为难治性高血压,即应用包含利尿剂的≥3种降压药物仍不能达标者.虽然难治性高血压的原因有很多,如依从性差、继发性高血压、配伍不合理和药物的相互作用等,但即使剔出这些因素,仍有5.0%的高血压患者属真正的顽固性高血压[1-2],因此,寻找新的治疗高血压的方法十分必要.继高血压疫苗之后,肾交感神经消融治疗为高血压的治疗提供了新的途径.     

顽固性高血压获得革命性突破——肾动脉去交感神经消融(ARDN)新闻发布会

2012年3月3日,在第15届全国介入心脏病学论坛新闻发布会上,大会主席霍勇教授表示,治疗难治性高血压获得了新突破。"经皮导管肾脏交感神经射频消融术"通过射频消融术切断肾脏交感神经,且不影响其他腹部、骨盆或下肢神经支配,达到了在降压的同时避免严重并发症的发生。这一新技术是第一次在全国性心血管学术会议上发布的。通过微创去除部分肾动脉交感神经,用来治疗难治性高血压,是高血压治疗领域革命性的突破。     

Sympathetic Nervous System and Age-Dependent Salt Hypertension in Brattleboro Rats

ABSTRACT

The effects of early sympathectomy on the development of salt hypertension were studied in prepubertal and adult rats with hereditary diabetes insipidus (DI). Early guanethidine administration caused a pronounced and long-term destruction of sympathetic nervous system (SNS) in Brattleboro rats in which blood pressure (BP) was significantly decreased until the age of 22 weeks. This SNS impairment did not abolish the age-dependent BP response of salt-loaded rats that was still greater in young than in adult sympathectcmized DI rats. BP of young uninephrectcmized DI rats was higher in the late than in the early phase of salt hypertension development. The early sympathectomy lowered BP and increased mortality in all groups of saline drinking DI rats except young uninephrectcmized animals in which hypertensive response was attenuated but not prevented.

It could be suggested that 1) increased BP response of young rats to high salt intake occurs even in animals with attenuated principal pressor systems, 2) the effects of early sympathectomy on the development of salt hypertension depend on the actual hemodynamic pattern, and 3) moderate BP increase might hie a part of homeostatic mechanisms defending the organism threatened by chronic salt overload.     

Unique resistance to guanethidine-induced chemical sympathectomy of spontaneously hypertensive rats: a resistance overcome by treatment with antibody to nerve growth factor.

The chronic administration of high doses of guanethidine to rats produces complete destruction of the peripheral sympathetic nervous system. In a study of the effect of guanethidine-induced sympathectomy on the development of hypertension is spontaneous hypertensive rats (SHR, Okomoto strain), only a partial sympathectomy could be produced as assessed by biochemical parameters (tyrosine hydroxylase activity in ganglia and tissue norepinephrine concentrations) and by evaluation of response to stimulation of vasomotor outflow in pithed rat preparations. Other strains of rats (Sprague-Dawley, American Wistar, Kyoto Wistar) were uniformly sensitive to guanethidine sympathectomy. The resistance to guanethidine was not due to a lower accumulation of guanethidine in the neurons of SHR. Addition to the guanethidine treatment of low doses of antibody to nerve growth factor (NGF), which itself produced only a modest sympathectomy, resulted in an almost complete sympathectomy. SHR did not become hypertensive when sympathectomized by combined guanethidine-anti NGF. These results show that the sympathetic neurons of SHR differ from those of other strains with respect to sensitivity to guanethidine cytotoxicity and suggest the possibility of a role for NGF in that altered responsiveness.     

Transcatheter therapies for resistant hypertension: Clinical review

Resistant hypertension(RHTN) is a commonly encountered clinical problem and its management remains a challenging task for healthcare providers. The prevalence of true RHTN has been difficult to assess due to pseudoresistance and secondary hypertension. Atherosclerotic renal artery stenosis(RAS) has been associated as a secondary cause of RHTN. Initial studies had shown that angioplasty and stenting for RAS were a promising therapeutic option when added to optimal medical management. However, recent randomized controlled trials in larger populations have failed to show any such benefit. Sympathetic autonomic nervous system dysfunction is commonly noted in individuals with resistant hypertension. Surgical sympathectomy was the treatment of choice for malignant hypertension and it significantly improved mortality. However, postsurgical complications and the advent of antihypertensive drugs made this approach less desirable and it was eventually abandoned. Increasing prevalence of RHTN in recent decades has led to the emergence of minimally invasive interventions such as transcatheter renal denervation for better control of blood pressure. It is a minimally invasive procedure which uses radiofrequency energy for selective ablation of renal sympathetic nerves located in the adventitia of the renal artery. It is a quick procedure and has a short recovery time. Early studies in small population showed significant reduction in blood pressure. The most recent Symplicity HTN-3 study, which is the largest randomized control trial and the only one to use a sham procedure in controls, failed to show significant BP reduction at 6 mo.     

Insulin Resistance,Energy Balance and Sympathetic Nervous System Activity

Insulin resistance and hyperinsulinemia are commonly associated with hypertension in the obese. The nature of this association is obscure. An hypothesis is developed that attributes obesity-related hypertension to sympathetic stimulation. The relationship between insulin and the sympathetic nervous system (SNS) has its origins in the mediation of dietary thermogenesis. Fasting suppresses while carbohydrate and fat feeding stimulate sympathetic activity. Insulin-mediated glucose metabolism within critical central neurons links dietary intake and central sympathetic outflow. The sympathetic nervous system, in turn, contributes to changes in metabolic rate that accompany alterations in dietary intake. It is hypothesized that insulin resistance is a mechanism recruited in the obese to limit further weight gain and stabilize body mass. Insulin-mediated sympathetic stimulation is one mechanism that may restore energy balance in the obese since the obese are not resistant to the stimulatory effect of insulin on the SNS. Sympathetically mediated stimulation of the heart, vasculature and kidney contributes, in genetically predisposed individuals, to the development of hypertension. Viewed in this light, obesity-related hypertension is the unfortunate by-product of an adaptive mechanism (insulin resistance) recruited to restore energy balance in the obese. Possible implications of this formulation are discussed.     

交感神经去除术在肺动脉高压治疗中的研究进展

肺动脉高压是一种复杂的临床综合征,虽然在心肺血管疾病中发病率不高,但因其严重影响患者生活质量,致死风险高,被称为心血管疾病中的恶性疾病。靶向药物治疗使得肺动脉高压病情得到一定程度控制,但整体控制率仍不容乐观。随着肺动脉高压相关研究的推进,目前认为交感神经的过度激活在肺动脉高压的发生和维持中起到一定作用,且基于调节自主神经活性的药物和器械治疗在肺动脉高压中的研究得到了一些发现。现就交感神经在肺动脉高压发生和发展的作用、肺动脉神经分布特点和交感神经活性调节的非药物治疗研究进行综述,以探讨肺动脉高压治疗的新思路。     

Surgical,Interventional, and Device Innovations in the Management of Hypertension

The prevalence of hypertension around the world has increased significantly with projections for an increasing major global burden of hypertension. Medication-resistant hypertension can be perplexing and frustrating. The existence of these difficult patients results in the need for additional approaches to treatment including surgery, percutaneous interventions, and device management. The sophistication of these techniques has progressed markedly and initial procedures such as classical sympathectomy and renal artery bypass are almost never performed. Newer techniques of angioplasty with stenting, renal artery denervation, and baroreflex activation therapy via electrical stimulation of the carotid baroreceptors are now in use with increasing evidence for significant benefit.     

Renal denervation in the treatment of resistant arterial hypertension and other perspectives

Renal denervation (RDN) is a new perspective method for the treatment of resistant hypertension. Surgical sympathectomy has been considered as a possible treatment of hypertension for many years—long before the discovery of antihypertensive drugs. The selective percutaneous transcatheter application of radiofrequency energy in renal arteries to eliminate sympathetic nerve fibers has been used in human medicine since 2009. The recent boom of this method has been supported by published clinical studies showing efficacy of this new treatment modality. Nevertheless, RDN is still an experimental method to be used only in specialized research centers. In this review we will provide up-to-date information about the use of RND as a novel method for the treatment of hypertension as well as discuss potential perspectives of RND in the treatment of various medical conditions.     

Sympathetic nerves modify mitochondrial and capillary growth in normotensive and hypertensive rats

We tested the hypothesis that sympathetic nerves influence cardiocyte organelle volumes and capillarity in spontaneously hypertensive rats (SHR) with long-standing hypertension and left ventricular hypertrophy. SHR and their normotensive, Wistar Kyoto (WKY), controls were treated with 6-hydroxydopamine from birth to prevent the establishment of the sympathetic nervous system. To determine whether beta adrenergic receptors were the major pathway of sympathetic influence, another group of SHR and WKY were chronically treated from weaning with the beta 1 adrenergic antagonist, metoprolol. In SHR sympathectomy failed to alter, while metoprolol attenuated, hypertension. Stereological analyses of perfuse-fixed hearts showed that in both SHR and WKY mitochondria/myofibrils volume ratio was increased by long-term sympathectomy, mainly by limiting mitochondrial volume density, even though this intervention failed to alter left ventricular mass. In contrast, long-term beta 1 blockade attenuated hypertrophy in SHR but had no effect on mitochondria/myofibrils volume ratio. Capillary numerical density was increased significantly in sympathectomized SHR and WKY. However, despite this increase, capillary volume density was similar in control and sympathectomized rats, since capillary diameter was less in the latter. Metoprolol-treated SHR showed a trend toward higher capillary numerical densities consistent with their attenuation of hypertrophy. These findings indicate that sympathetic nerves, either directly or indirectly, inhibit cardiocyte mitochondrial growth and capillary proliferation during both normal and pressure-overload induced cardiac enlargement.     

Renal Denervation: A Potential New Treatment for Severe Hypertension

Hypertension is a leading cause of cardiovascular morbidity and mortality. Drug‐resistant hypertension remains common despite the availability of several classes of effective antihypertensive agents. Sympathetic hyperactivity has long been recognized as a major contributor to resistant hypertension, but radical sympathectomy was abandoned several decades ago due to its significant side effects. The newly developed, minimally invasive, catheter‐based renal sympathetic denervation procedure has been shown in recent trials to produce impressive blood pressure reductions and a favorable safety profile in drug‐resistant hypertension. Although the long‐term efficacy and safety of renal denervation remains to be determined, emerging data suggest that the benefits of renal denervation may extend beyond blood pressure control. Dr. Cohen is the principal investigator for Symplicity 3 study funded by Medtronic; Dr. Huan is the subinvestigator for Symplicity 3 study funded by Medtronic.     

心房颤动导管消融联合肾交感神经消融——心房颤动合并高血压治疗的新策略？

心房颤动是临床上最常见的一种心律失常,它可以影响血流动力学和增加脑卒中的风险。近年来心房颤动导管消融发展迅速,但是导管消融治疗心房颤动仍可能复发房性心律失常,目前单纯导管消融治疗心房颤动长期维持窦性心律的成功率还不尽如人意。肾交感神经消融通过抑制交感神经系统及肾素-血管紧张素-醛固酮系统活性从而达到治疗顽固性高血压的目的,现已成为一种有效、安全的新型手术方法。原发性高血压、心房颤动和交感神经系统三者之间有着密不可分的关系,肾交感神经消融可能通过抑制交感神经系统和肾素-血管紧张素-醛固酮系统活性减少心房颤动复发,也许将会成为心房颤动合并高血压治疗的新策略。现就导管消融联合肾交感神经消融治疗心房颤动的相关内容进行综述。