A simplified approach to the treatment of hypertension

A new beta-adrenoreceptor blocking drug (timolol) was used in two clinical studies. In the first double blind study administration of hydrochlorothiazide and timolol reduced the mean (formula: see text) blood pressure by 23 mm Hg, compared with a fall of nine mm Hg with administration of hydrochlorothiazide and a placebo. Plasma potassium (K+) levels fell with the administration of hydrochlorothiazide alone, but rose back to control values when patients were given timolol. In the second study (patient blind), Moduretic (hydrochlorothiazide, 50 mg and amiloride, 5 mg) and timolol were given once daily. The mean blood pressure fell by 20 +/- 2 mm Hg allowing hypertension to be controlled by this once-daily regimen; the control persisted throughout the day. Plasma potassium (K+) levels fell slightly after treatment with Moduretic, but the fall was not as great as with hydrochlorothiazide. Of the 65 patients who entered these studies, 35 had not been previously treated and had diastolic blood pressure between 105 mm Hg and 130 mm Hg. In 18 patients the diastolic blood pressure was reduced below 95 mm Hg after treatment with a diuretic alone, in 15 patients treatment with a diuretic and timolol (5 mg to 20 mg) reduced the diastolic blood pressure below 95 mm Hg. In two patients, the diastolic blood pressure was between 95 mm Hg and 100 mm Hg. The response achieved with a relatively simple therapeutic regimen that can be administered once daily suggests that the therapy of most hypertensive patients could be supervised by paramedical personnel.     

An assessment of diltiazem and hydrochlorothiazide in hypertension. Application of factorial trial design to a multicenter clinical trial of combination therapy

This multicenter, factorial-design trial assessed the safety and additive antihypertensive efficacy of a slow-release (SR) formulation of diltiazem hydrochloride given alone or in combination with hydrochlorothiazide for treatment of mild to moderate hypertension. After a 4- to 6-week placebo run-in period, 297 qualifying patients were randomized to receive placebo, 1 of 4 doses of diltiazem SR monotherapy, 1 of 3 doses of hydrochlorothiazide monotherapy, or 1 of 12 possible combinations of diltiazem SR and hydrochlorothiazide for 6 weeks. A dose-related reduction in blood pressure was demonstrated for each drug as monotherapy and for the two drugs in combination. Absolute blood pressures of patients who received combination therapy were lower by an overall mean of 3.0 mm Hg diastolic and 8.0 mm Hg systolic vs diltiazem SR used alone and 3.5 mm Hg diastolic and 4.0 mm Hg systolic vs hydrochlorothiazide used alone. At the largest doses used, 50% of patients achieved goal blood pressure while taking hydrochlorothiazide, 57% while taking diltiazem SR, and 75% while taking combination therapy. Combination therapy was well tolerated. This trial clearly demonstrates that diltiazem SR and hydrochlorothiazide have additive antihypertensive effects.     

SARS临床诊断病例1291例糖皮质激素治疗不良反应分析

目的:探讨严重急性呼吸综合征(severe acute respiratory syndrome,SARS)治疗中糖皮质激素(glucocorticosteroids,GCS)的使用与不良反应的关系.方法:收集北京市SARS病历资料,建立数据库,回顾分析1 291例临床诊断SARS病例.按照GCS起始剂量、日最大剂量和累积剂量分组,均换算为甲泼尼龙(methyprednisonlone,MP)剂量.使用SAS 8.10软件统计GCS相关不良反应,包括血糖增高(≥7.8 mmoL/L)、低钾血症(＜3.5 mmol/L)、低钙血症(＜2.12 mmol/L)、收缩压升高[≥140 mm Hg(1 mm Hg=0.133 kPa)]及舒张压升高(≥90 mm Hg).结果:GCS组1 084例,未用GCS组207例.GCS平均日使用剂量总趋势是递减,早期日平均剂量(中位数)为160 mg/d,10天后下降,13天降到80 mg/d.GCS组病程中最高血糖(8.68±4.80)mmol/L,未用GCS组(6.39±3.71)mmoL/L,两组比较差异有显著性(P＜0.001).MP起始≥80 mg/d,MP最大≥160 mg/d以及MP累积≥3 000 mg各组的平均血糖均明显升高.使用GCS后第1～2周血糖升高最显著,而后逐渐下降.MP累积≥3 000 mg组血糖增高且持续时间延长,与其它组比较差异有显著性(P＜0.05).GCS组病程中最低血钾为(3.66±0.50)mmoL/L,低钾持续时间1(1,75)天,与未用GCS组(4.01±0.51)mmol/L,1(1,9)天比较差异具有显著性(P＜0.05).GCS使用后第1周血钾降低最明显,第2周血钾回升.MP起始≥320 mg/d、MP最大≥320 mg/d、MP累积≥3 000 mg与较低剂量组比较,血钾明显降低(P＜0.001);且低钾持续时间长,到第3周才回升.GCS组低血钙持续19(1,74)天,未用GCS组为8(1,32)天,两组比较差异有显著性(P＜0.05).低血钙持续时间随最大剂量、累积剂量增加而延长.MP累积＜999 mg组与未用GCS组比较低血钙持续时间相近.GCS使用后收缩压和舒张压逐渐升高,第4周升高最显著.结论:血糖增高水平、低血钾水平和持续时间与GCS的剂量和疗程关系密切.GCS影响低血钙持续时间,使收缩压和舒张压逐渐升高.使用适当剂量的GCS(MP起始＜159 mg/d,MP最大＜159 mg/d、MP累积＜2 999 mg)可以避免血糖、血钾、血钙的明显异常.使用GCS较大剂量时密切监测上述指标变化对临床治疗具有重要价值.     

Diuretics, serum and intracellular electrolyte levels, and ventricular arrhythmias in hypertensive men.

OBJECTIVE--To investigate the patterns of electrolyte abnormalities resulting from thiazide administration and whether they cause ventricular arrhythmias, and to help resolve the controversy over whether clinicians should routinely prescribe potassium-conserving therapy to all patients treated with thiazides. DESIGN--Double-blind, randomized controlled trial. PARTICIPANTS--A total of 233 hypertensive men aged 35 to 70 years. INTERVENTIONS--Participants were withdrawn from prior diuretic treatment and were replenished with oral potassium chloride and magnesium oxide. They were then randomized to 2 months of treatment with (1) hydrochlorothiazide; (2) hydrochlorothiazide with oral potassium; (3) hydrochlorothiazide with oral potassium and magnesium; (4) hydrochlorothiazide and triamterene; (5) chlorthalidone; or (6) placebo. MAIN OUTCOME MEASURES--Ventricular arrhythmias on 24-hour Holter monitoring and serum and intracellular potassium and magnesium levels. RESULTS--Of the 233 participants, 212 (91%) completed the study. Serum potassium levels were 0.4 mmol/L lower in the hydrochlorothiazide group than in the placebo group (P less than 0.01), and this mean difference was not affected by supplementation with potassium, with potassium and magnesium, or with triamterene. However, the supplements did prevent the occasional occurrence of marked hypokalemia; all 12 of the men who developed serum potassium levels of 3.0 mmol/L or less were among the 90 who received diuretics without supplementation (P less than 0.01). Similarly, the overall proportion of men with ventricular arrhythmias was not affected by randomized treatment, but there was a twofold increase in the proportion with arrhythmias among the 12 men with serum potassium levels of 3.0 mmol/L or less (P = .02). Serum magnesium and intracellular potassium and magnesium levels were not reduced by hydrochlorothiazide, nor were they related to ventricular arrhythmias. CONCLUSIONS--In the majority of hypertensive patients, treatment with 50 mg/d of hydrochlorothiazide does not cause marked hypokalemia or ventricular arrhythmias. However, because some individuals will develop hypokalemia after starting diuretic therapy, serum potassium levels should be monitored and potassium-sparing strategies should be used when indicated.     

Hypokalemia during the treatment of arterial hypertension with diuretics.

In a study of 50 patients with uncomplicated arterial hypertension the administration of hydrochlorothiazide, 50 to 100 mg daily or every other day, with or without reserpine, 0.25 mg daily, resulted in a fall in the mean blood pressure from 182/113 to 144/92 mm Hg. The mean duration of therapy was 19 months. The mean serum potassium concentration was 4.3 mmol/l before the onset of therapy. It fell during the first 6 weeks of treatment, but seldom below 3.5 mmol/l, then rose gradually and spontaneously to 4.1 mmol/l after 19 months of therapy. All the patients remained asymptomatic. These findings bring into question the routine use of potassium supplements or a potassium-sparing diuretic, such as spironolactone or triamterene, during the treatment of hypertension with diuretics such as the thiazides. The use of potassium supplements or a potassium-sparing agent may induce hyperkalemia in spite of the simultaneous administration of a diuretic that acts more proximally. Since hyperkalemia is potentially lethal, the serum potassium concentration should be carefully monitored in any patient receiving potassium supplements or a potassium-sparing agent.     

Antihypertensive treatment with metoprolol or hydrochlorothiazide in patients aged 60 to 75 years. Report from a double-blind international multicenter study

In a randomized double-blind study (N = 562), a traditional treatment schedule, starting antihypertensive treatment in elderly hypertensive patients (60 to 75 years old) with 25 mg of hydrochlorothiazide once daily and doubling the dose if a satisfactory response was not achieved, was compared with antihypertensive treatment of 100 mg of metoprolol once daily, adding 12.5 mg of hydrochlorothiazide for patients whose response was not satisfactorialy achieved with metoprolol alone. Systolic and diastolic blood pressure was significantly reduced with both regimens. The frequency rates of responders (diastolic blood pressure, less than or equal to 95 mm Hg) in the metoprolol group and the hydrochlorothiazide group were 50% and 47% after four weeks and 65% and 61% after eight weeks, respectively. There were no significant differences in total symptom score or single symptoms between the regimens, but significantly more patients had hypokalemia and hyperuricemia with the hydrochlorothiazide regimen. Thus, we conclude that beginning antihypertensive treatment with 100 mg of metoprolol once daily and adding a small dose of hydrochlorothiazide (12.5 mg) in patients whose response is not satisfactory with metoprolol alone appears to be effective and safe in elderly hypertensive patients.     

Beta blockade, diuretics, and salt restriction for the management of mild hypertension: a randomised double blind trial

Ninety four patients with mild hypertension (average supine diastolic blood pressure (phase V) 95-110 mm Hg) were allocated at random to receive restriction of dietary sodium (maximum allowed 70 mmol(mEq)/24 h) or a normal diet. In addition, they received in random order 25 mg chlorthalidone, 200 mg metoprolol (slow release), and a fixed combination of these two drugs. Each drug treatment was given for four weeks and alternated with four weeks of placebo. Forty four patients were allocated to sodium restriction (group 1) and 50 to normal diet (group 2). The mean 24 hour urinary sodium excretion in group 1 was 74 (SD 31) mmol(mEq)/24 h, and in group 2 132 (51) mmol/24 h. Compared with the screening blood pressure the average decrement of the supine blood pressure in group 1 was 16.0/8.6 mm Hg with placebo, 21.7/11.5 mm Hg with the diuretic, 28.5/17.8 mm Hg with the beta blocker, and 28.9/18.4 mm Hg with the combined agent; in group 2 these values were 13.3/6.1, 20.3/9.7, 21.3/12.9, and 29.4/16.8 mm Hg, respectively. There was a sharp decrease of the average potassium concentration during chlorthalidone and combination treatment periods (average value 3.3 mmol(mEq)/1). These results suggest that moderate salt restriction used as sole treatment has a limited though demonstrable blood pressure lowering effect but that when it is used as an adjuvant to beta blocker treatment its value is greatly enhanced.     

Treatment of arterial hypertension with tienilic acid, a new diuretic with uricosuric properties.

Tienilic acid--2,3-dichloro-4-(2-thienyl-carbonyl)phenoxyacetic acid--is a new diuretic with uricosuric properties. Nineteen patients with moderate arterial hypertension were treated for 5 consecutive weeks in a randomized fashion in a double-blind study with either tienilic acid or hydrochlorothiazide. Blood pressure was significantly reduced and to the same degree with both drugs. In 7 of the 11 patients receiving tienilic acid the daily dose was increased from 250 to 500 mg after 2 weeks, and in 2 of the 8 patients taking hydrochlorothiazide the daily dose was increased from 50 to 100 mg. Because of the potent uricosuric action of tienilic acid the mean serum urate concentration decreased from 6.3 to 3.3 mg/dL in the patients taking the drug. In contrast, the patients receiving hydrochlorothiazide the mean serum urate concentration increased from 6.1 to 7.8 mg/dL. Moderate hypokalemia of almost identical degree (mean serum potassium values 3.6 and 3.5 mmol/L) and mild metabolic alkalosis were observed in both groups. Tienilic acid had a marked hypocalciuric effect, which was of the same magnitude as the observed with hydrochlorothiazide. During the 5 weeks of treatment no significant change in renal or liver function was observed in either group. There were no hematologic complications and the drug was remarkably well tolerated. Tienilic acid, because of its unique character as a diuretic, hypouricemic and antihypertensive agent, should become the preferred drug for the treatment of arterial hypertension.     

BMI对血压、血糖、糖化血红蛋白及C肽的影响

目的：探讨年龄32～56岁的健康者体质指数（body mass index,BMI）增高对血压、血糖、糖化血红蛋白及C肽的影响。方法：79名健康者按BMI分为标准组（18.5≤BMI〈24,n=44）、超重组（24≤BMI〈28,n=27）及肥胖组（BMI≥28,n=8）三组,比较三组之间血压、血糖、糖化血红蛋白及C肽的变化。结果：随着BMI的增高,收缩压（SBP）[（115.8±15.24）mm Hg vs（121.1±18.38）mm Hg vs（133.4±18.36）mm Hg]（1 mm Hg=0.133 kPa）、餐后2 h血糖（PBG）[（5.76±0.73）mmol/L vs（5.86±0.76）mmol/L vs（6.61±1.85）mmol/L],及糖化血红蛋白（HbA1C）[（5.20±0.29）%vs（5.29±0.28）%vs（5.64±0.53）%]显著增高,差异有统计学意义（P=0.033,P=0.048,P=0.004）;而舒张压（DBP）[（72.57±11.14）mm Hg vs（75.81±10.04）mm Hg vs（80.71±11.31）mm Hg]、空腹血糖（FBG）[（5.73±0.52）mmol/L vs（5.48±0.54）mmol/L vs（5.85±0.61）mmol/L]、空腹C肽[（1.37±0.81）pmol/L vs（1.26±0.43）pmol/L vs（1.98±0.75）pmol/L]及餐后2 h C肽[（2.70±1.14）pmol/Lvs（2.99±1.49）pmol/L vs（3.25±1.53）pmol/L]也有增高趋势,但差异无统计学意义（P=0.137,P=0.107,P=0.110,P=0.530）。结论：肥胖使血压、血糖水平增加,从而增加高血压以及糖尿病的患病风险。     

126例支气管哮喘急性发作患者血钾水平分析

目的探讨支气管哮喘急性发作并发低钾血症的临床特点。方法 126例确诊为中、重度支气管哮喘患者为哮喘组,根据静脉应用糖皮质激素不同将其分为地塞米松亚组及甲基强的松龙亚组,对照组为同期收治的150例肺炎患者,测定患者血钾水平并进行统计分析。结果哮喘组血钾水平明显低于对照组[（3.47±1.26）vs（3.82±1.01）,P〈0.01],地塞米松亚组血钾水平低于甲基强的松龙亚组[（3.39±1.37）vs（3.49±1.66）,P〈0.05],哮喘组低钾血症发生率高于对照组（28.6%vs 7.3%,P〈0.01）,地塞米松亚组低钾血症发生率高于甲基强的松龙亚组（61.49%vs11.0%,P〈0.01）。结论支气管哮喘急性发作合并低钾血症的发生率高,应用地塞米松增加发生低钾血症危险。     

源于腹腔间隙综合征的急性肾功能衰竭

目的研究腹腔压力的增高对肾功能的影响。方法30例腹腔压力升高患者,男26例,女4例,平均年龄42岁±17岁。每日在同一时间检测患者腹腔压力,记录平均动脉压、中心静脉压,同时留取血液标本检测血清肌酐。结果当腹腔压力升高时,尿量由基础水平的78ml/h±26ml/h减少至31ml/h±11ml/h(P<0.01),同时血清肌酐由110mmol/L±98mmol/L增至224mmol/L±147mmol/L(P<0.01),伴随中心静脉压(由6.0mmHg±2.1mmHg至8.8mmHg±2.5mmHg,1mmHg=0.133kPa,P<0.01)和平均动脉压(由79mmHg±8mmHg至86mmHg±10mmHg,P<0.01)的升高。腹腔压力的上升与尿量呈负相关(r=-0.747,P<0.01);与血清肌酐呈正相关(r=0.816,P<0.01)。在随后的治疗中12例患者死亡,其中8例死于脓毒血症引起的多脏器功能衰竭,4例死于腹腔大出血。结论患者腹腔压力的上升与少尿、血清肌酐上升密切相关;腹腔压力降低后,上述临床结果得到改善。     

氨氯地平联合阿托伐他汀治疗原发性高血压76例临床分析

目的 对氨氯地平联合阿托伐他汀在原发性高血压中的临床价值进行分析.方法 选取2009年2月至2013年1月在江苏省第二中医院住院治疗的高血压患者76例,根据是否使用氨氯地平联合阿托伐他汀分为两组,分别为联合用药组（38例）和氢氯噻嗪组（38例）,联合用药组采用氨氯地平（每次5 mg,每日1次）联合阿托伐他汀（每次10 mg,每日1次）;氢氯噻嗪组采用氢氯噻嗪（每次6.25 mg,每日1次）进行治疗,与治疗前和治疗8周后对联合用药组和氢氯噻嗪组患者的血压、微量尿蛋白和臂踝脉搏波传导速度进行观察分析.结果 联合用药组患者在治疗后8周的收缩压为（140.25±11.94） mm Hg、舒张压为（84.38±8.75） mm Hg均分别低于氢氯噻嗪组患者的收缩压（84.38±8.75） mm Hg、舒张压（87.25±8.83） mm Hg;治疗后8周的微量尿蛋白为（15.39±5.28） mg/L显著低于氢氯噻嗪组患者的（29.37±13.21） mg/L;联合用药组患者的臂踝脉搏波传导速度为（1558.31±278.55） cm/s显著低于氢氯噻嗪组患者的（1701.63±529.62） cm/s（P＜0.05）.结论 氨氯地平联合阿托伐他汀可以有效地治疗原发性高血压.     

血清总胆红素水平检测在脑梗死突发事件中的应用

目的 观察分析血清总胆红素水平检测在脑梗死突发事件中的相关应用.方法 选取2013年9月至2015年7月德宏州人民医院收治的脑梗死患者 (发病≤2周) 62例作为观察组, 另选取同期体检正常者62例作为对照组.观察比较2组受试者入院72 h内的血清总胆红素、血脂、血糖等生化指标水平.结果 观察组患者的三酰甘油、总胆固醇、高密度脂蛋白胆固醇、舒张压、收缩压、空腹血糖均显著高于对照组[ (1.85±0.36) mmol/L vs (1.36±0.21) mmol/L, (4.9±1.5) mmol/L vs (4.5±1.1) mmol/L, (1.56±0.39) mmol/L vs (1.43±0.28) mmol/L, (83.1±11.5) mm Hg vs (75.2±10.3) mm Hg, (132.5±22.4) mm Hg vs (117.3±19.8) mm Hg, (5.9±0.3) mmol/L vs (5.3±0.9) mmol/L], 低密度脂蛋白胆固醇低于对照组[ (2.01±0.29) mmol/L vs (2.41±0.37) mmol/L].观察组患者的血清总胆红素、直接胆红素、间接胆红素显著均高于对照组[ (15.1±3.8) μmol/L vs (12.1±3.5) μmol/L, (4.6±1.1) μmol/L vs (3.9±1.3) μmol/L, (10.5±2.1) μmol/L vs (8.1±1.4) μmol/L] (P<0.05) .不同程度神经功能缺损患者总胆红素、直接胆红素、间接胆红素比较差异无统计学意义 (P>0.05) .预后良好组患者总胆红素、直接胆红素、间接胆红素水平均显著高于预后不良组[ (16.1±3.7) μmol/L比 (11.9±2.9) μmol/L、 (4.9±1.1) μmol/L比 (3.6±1.1) μmol/L、 (11.2±2.1) μmol/L比 (8.2±2.3) μmol/L] (P<0.05) .结论 对血清总胆红素水平检测, 能够了解患者胆红素水平, 有利于对脑梗死患者的早期诊断和治疗, 同时判断患者预后.     

Moderate sodium restriction with angiotensin converting enzyme inhibitor in essential hypertension: a double blind study

Fifteen unselected patients who had essential hypertension and whose average supine blood pressure when they were not receiving any treatment and their usual sodium intake was 162/107 mm Hg were treated with captopril 50 mg twice daily. After one month's treatment their supine blood pressure had decreased to 149/94 mm Hg. They were then instructed to reduce their sodium intake to about 80 mmol(mEq)/day. After two weeks of moderate sodium restriction they were entered into a double blind randomised crossover study comparing the effect of 10 Slow Sodium tablets (100 mmol sodium chloride) with matching placebo tablets while continuing to take captopril and restrict sodium in their diet. After one month of taking placebo their mean supine blood pressure was 137/88 mm Hg with a urinary sodium excretion of 83 mmol/24 h, while after one month of taking Slow Sodium tablets their mean supine blood pressure was 150/97 mm Hg (p less than 0.001) with a sodium excretion of 183 mmol/24 h. The mean supine blood pressure during moderate sodium restriction therefore decreased by 9% and correlated significantly with the reduction in urinary sodium excretion. These results suggest that the combination of treatment with a moderate but practical reduction in sodium intake and an angiotensin converting enzyme inhibitor is effective in decreasing the blood pressure in patients with essential hypertension. This combined approach overcomes some of the objections that have been made to salt restriction alone and to converting enzyme inhibitors alone.     

重症脑血管病并发高渗血症患者的护理监测进展

目的探讨重症脑血管病并发高渗血症患者的护理监测疗效。方法选取我院2009年1月～2011年6月收治的重症脑血管病并发高渗血症老年患者30例,对所有患者进行有效的护理监控,主要内容包括患者血糖、血钠、血钾的监测,进而控制机体补液量、利尿药用量、血糖水平,动态观察患者干预前后血浆渗透压的变化情况,分析比较患者护理监测干预前后的临床疗效。结果护理监测干预后患者血浆渗透压[（301.3±10.5）mmol/L]、血钠[（138.2±5.4）mmol/L]、血糖[（7.9±1.8）mmol/L]、血尿素氮[（7.4±2.3）mmol/L]均明显低于护理监测干预前患者的血浆渗透压（329.8±17.6）mmol/L、血钠（147.9±8.0）mmol/L、血糖（8.7±2.5）mmol/L、血尿素氮（9.6±3.1）mmol/L。护理监测干预后患者血钾（4.9±0.7）mmol/L明显高于护理监测干预前患者血钾（4.1±0.6）mmol/L。护理监测干预成功患者住院病死率（22.7%）明显低于护理监测干预不成功患者住院病死率（100.0%）。差异均有统计学意义（均P〈0.05）。结论对重症脑血管病并发高渗血症患者采取有效的护理监测措施,可以大幅降低患者的血浆渗透压,进而改善患者重症脑血管病病情,降低住院病死率,是一种安全有效的治疗方法,值得临床推广使用。     

Cardiovascular effects of training for a marathon run in unfit middle aged men

The effects of a 30 week exercise programme on serum lipid values, blood pressure, and cardiac function were assessed in a group of sedentary men aged 35-50 training for their first marathon. Mean serum cholesterol concentration (n = 33) fell by 12% from 6.54 (SE 0.18) to 5.76 (0.15) mmol/l (mean fall 0.78 mmol/l; 95% confidence interval 0.52 to 1.04 mmol/l), serum triglyceride concentration (n = 33) by 22% from 1.56 (0.17) to 1.21 (0.09) mmol/l (mean fall 0.34 mmol/l; 95% confidence interval 0.12 to 0.56 mmol/l), and mean blood pressure (n = 27) by 10% from 102 (2) to 92 (2) mm Hg (mean fall 10 mm Hg; 95% confidence interval 7 to 13 mm Hg). These changes were not explained by changes in body composition. Peak exercise left ventricular end diastolic volume (n = 16) increased with training; as a result of this and an increased exercise left ventricular ejection fraction peak exercise cardiac output increased from 19.9 (1.2) to 23.1 (3.0) l/min (mean rise 3.2 l/min; 95% confidence interval 1.5 to 5.0 l/min). Maximum oxygen consumption increased from 33.9 (1.6) to 39.0 (1.3) ml/kg/min (mean rise 5.0 ml/kg/min; 95% confidence interval 1.8 to 8.2 ml/kg/min). This study showed favourable effects on coronary risk factors and cardiac function and supports the place of regular exercise in coronary prevention programmes.     

严重低钾血症致麻醉后潜在致命性心律失常1例的术中管理

<正>严重低钾血症的定义为血清钾离子浓度低于2.5 mmol/L,如不及时有效救治可引起严重的心律失常和呼吸肌麻痹而危及患者生命[1]。低钾血症常由于患者长期进食不足,应用排钾利尿剂,呕吐、持续胃肠减压,钾离子向组织内转移等原因导致。清醒患者出现低钾血症最早的临床表现是肌无力,一旦出现呼吸肌受累,可致呼吸困难或窒息。全身麻醉的患者可仅表现为心律失常,典型的心电图表现为T波低平或倒置,随后出现ST段降低、QT间期延长和U波[2]。     

表现为严重低钙血症、周期性麻痹的Gitelman 氏综合征

患者,女,63岁,因反复乏力,双下肢瘫痪,双手搐搦50 年,加重2 年入院。查体:P80/min,BP120/70mmHg,BMI23.0kg/m2,WHR0.84,焦虑,四肢肌力正常,膝反射、踝反射轻度减弱。无阳性家族史,无服用利尿剂及泻药史。实验室检查示低血钾(2.77～3.17mmol/L),低血镁(0.31～0.35mmol/L),低血钙(1.79～1.99mmol/L),和低尿钙(0.12～1.10mmol/24h)。血浆肾素活性升高,血浆醛固酮水平正常,PTH水平正常。尿钙及尿肌酐比低(5.17～23.57×10-3mg/mgCr),血气分析显示代谢性碱中毒。在该患者进行的速尿或双氢克尿噻的清除率试验中,使用速尿后其尿量及氯离子的清除率增加,远端肾小管氯离子的重吸收分数降低;而使用双氢克尿噻后以上变化均不明显,提示缺陷位于远曲小管而不是亨利氏襻的厚壁升之段。因此,Gitelman氏综合征(Gitelman'ssyndrome,GS)诊断明确。给予消炎痛50mg,tid治疗3d后,复查患者的血钾水平开始上升,但血镁及血钙水平无明显改善,加用氨苯蝶啶50mg,tid治疗,4d后发现血钾及血钙水平恢复正常,血镁从0.35mmol/L升到0.52mmol/L出院;院外随访18个月,复查血钾、血钙及血镁水平完全恢复正常。GS可伴有严重低钙血症、周期性麻痹,肾脏清除率试验在临床上可帮助诊断,消炎痛及氨苯蝶啶联合应用治疗有效。     

调节透析液钾浓度对血液透析患者电解质紊乱和心血管稳定性的影响

目的探讨调节透析液钾浓度对血液透析患者电解质紊乱和心血管稳定性的影响。方法选取大埔县人民医院行维持性血液透析的患者15例共707次透析,其中69例次行高钾透析液透析治疗作为观察组,选择每例患者行高钾透析治疗前5次透析共75例次为对照组;分别采用含钾浓度为3.0~4.0 mmol/L、2.0~2.5 mmol/L的透析液进行透析治疗。测定透析前后两组患者K+、Na+、CL-的浓度,并记录心血管并发症发生情况。结果透析后,对照组K+浓度明显降低,为(3.03±0.05)mmol/L,且显著低于观察组的(3.74±0.08)mmol/L,差异有统计学意义(P0.05);观察组Na+、CL-浓度显著升高,而对照组无明显变化,两组比较差异有统计学意义(P0.05)。观察组血压下降和心律失常的发生率分别为7.25%和15.94%,均显著低于对照组的36.00%和46.67%(P0.05)。随访1年后,观察组心率正常和动脉硬化指数均显著优于对照组,差异有统计学意义(P0.05)。观察组患者心慌、胸闷及气促的发生率均显著低于对照组,差异有统计学意义(P0.05)。结论电解质紊乱、血压下降和心律失常是血液透析治疗中的常见并发症,临床上若采用3.0~4.0 mmol/L钾浓度的透析液进行透析可有效纠正电解质紊乱和维持心血管稳定性。     

洛阳市383例冠心病患者多种危险因素达标率分析

目的了解已诊断为冠心病患者各种危险因素治疗达标率情况。方法以383例已被诊断为冠心病的患者为调查对象,依据中国成人血脂防治指南对各种危险因素的控制建议分析该群患者的治疗控制情况。结果总胆固醇〈4．14mmol／L的比率为9．92％（38／383）,甘油三酯〈1．70mmol／L的比率为20．6％（79／383）,低密度脂蛋白胆固醇（LDL—C）〈2．59mmol／L的比率为10．7％（41／383）,高密度脂蛋白胆固醇（HDL—C）〉1．04mmol／L的比率为70．8％（271／383）;收缩压〈140mmHg（1mmHg=0．133kPa）的比率为44．9％（172／383）,舒张压〈90mmHg的比率为39．7％（152／383）,血压（BP）〈140／90mmHg的比率为26．4％（101／383）;空腹血糖〈6．1mmol／L的比率为73．4％（281／383）,餐后2h血糖〈7．8mmol／L的比率为76．9％（302／383）;男性腰围〈90cm的比率为19．9％（40／201）,女性腰围〈85cm的比率为17．6％（32／182）;不吸烟的比率为94．3％（361／383）。将LDL—C〈2．59mmol／L,BP〈140／90mmHg,空腹血糖〈6．1mmol／L,男性腰围〈90cm,女性腰围〈85cm,不吸烟定义为全面达标,全面达标率为4．96％（19／383）。结论洛阳市某区冠心病患者的全面达标率较低,应加强综合防治。