112例难治性高血压临床分析

目的 分析难治性高血压的影响因素,为正确诊断和有效治疗难治性高血压提供帮助.方法 对2008～2010年我科112例难治性高血压患者和112例非难治性高血压患者的临床资料进行统计分析.结果 112例难治性高血压患者中,男性68例,女性44例,平均年龄(55±14.5)岁;对照组中,男性64例,女性48例,平均年龄(56±13.9)岁.难治性高血压组中继发性高血压38例(33.9％),对照组中继发性高血压9例(8.1％)(P＜0.01).难治性高血压组合并糖尿病22例(19.6％),并发肾功能不全25例(22.3％),对照组上述结果分别为9例(8％)(P＜0.05)和10例(8.9％)(P＜0.01).结论 难治性高血压影响因素较多,继发性高血压、糖尿病及肾功能不全是难治性高血压的重要影响因素.     

难治性高血压临床治疗

难治性高血压的治疗仍存在许多问题亟待解决,国内外就难治性高血压也均有指南和( 或) 共识指导临床工 作,本篇主要结合欧洲和中国难治性高血压指南和共识,从其概念、原因、诊断和治疗方面进行阐述。难治性高血压 的诊断必须首选排除假性难治性高血压、继发性高血压。难治性高血压的治疗包括建议患者健康的生活方式、继发 性高血压的病因治疗和合理的药物联合方案。     

难治性高血压的评估和治疗

难治性高血压(RH) 是一种导致心脑血管疾病进展的高血压,明确的诊断和有效的治疗至关重要。文章对顽 固性高血压的定义、病因、诊断及治疗进行了详细的总结。难治性高血压在治疗要强调个体化,需要仔细地甄别病 因、继发性高血压。动态血压监测及家庭血压测量需作为重要的诊断手段。合理、最佳、可耐受剂量的多种药物联 合治疗( 包括利尿剂) 是控制血压的关键。     

难治性高血压诊治的研究进展

难治性高血压又称顽固性高血压,是临床上一种特殊类型的高血压,其更易导致心血管疾病及靶器官损伤,因此有效诊断十分重要。本文主要综述了难治性高血压的定义、原因及治疗,以期为临床医师提供难治性高血压诊治的相关思路。     

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。     

2018美国心脏协会难治性高血压的诊治管理科学声明

正近日,美国心脏协会(American Heart Association,AHA)发布了新版《2018AHA难治性高血压的诊治管理科学声明》[1],这是对2008年发布的难治性高血压科学声明的更新,反映了过去10年间新的科学证据。声明的重点内容包括定义的更新、诊断、评估及管理流程。本版难治性高血压诊断与治疗声明较上一版有了一些改变,但是总体构思相似,仍然存在许多不     

生物反馈治疗对伴有焦虑症的难治性高血压的影响

目的:探讨生物反馈治疗对伴有焦虑症的难治性高血压的降血压作用.方法:分别观测伴有焦虑症的难治性高血压患者加用生物反馈治疗前后的血压及SAS评分.结果:难治性高血压患者,加用生物反馈治疗后其血压明显降低(P<0.01),SAS评分也较治疗前明显降低(P<0.01).结论:部分原发性高血压患者因伴有焦虑症,仅用降血压药物难以理想控制血压,加用生物反馈治疗能缓解焦虑情绪并有利于降低血压.     

难治性高血压的诊断与治疗

难治性高血压的诊断与治疗华西医科大学附属一院罗雪琚综述多数难治性（或称顽固性，Ｒｅｑｚａｃｔｏｒｙ；或称有抵抗的，Ｒｅｓｉｓｔａｎｔ）高血压是可找到原因的，如：患者对治疗的非依从性、药物的相互作用、假性高血压、“白大衣高血压”以及继发性高血压的原因等...     

浅析继发性高血压的诊断思路与规范 （附 2例临床诊治病例）

继发性高血压是难治性高血压的重要原因之一,其心脑血管风险增高,而去除病因或针对性的治疗可以显著获益,故继发性高血压的规范诊断和治疗尤为重要。本文通过对两个病例的报告和分析,强调规范继发性高血压诊治的重要性并探讨可能两种继发性高血压共病时的诊断与治疗思路。     

难治性高血压及其药物治疗

难治性高血压是全科医生乃至高血压专科医生面临的常见问题, 占高血压患者的20%~30%。评估是否为难 治性高血压必须以正确的血压测量为前提, 同时还应该明确患者是否存在有依从性差、生活模式不良及药物匹配不 合理等原因造成的假性难治性高血压的可能。难治性高血压常有多种病因, 继发性高血压是难治性高血压的重要 原因, 寻找病因对于制定治疗方案极为重要。难治性高血压药物治疗的成功与否很大程度上取决于经治医生的经验, 成功的治疗必须建立在对临床资料进行充分评估和积极而全面干预的基础之上。     

Descending aorta–external iliac artery bypass for middle aortic syndrome

We encountered a surgical case of middle aortic syndrome (MAS) in a 56-year-old man who had resistant hypertension. Computed tomography showed severe stenosis of the abdominal aorta from below the superior mesenteric artery to above the inferior mesenteric artery. Although bilateral renal artery stenosis was confirmed, renal function was within normal limits. A 10-mm vascular prosthetic graft was used to perform a descending aorta to left external iliac artery bypass. His hypertension was well controlled without medication. This extra-anatomic bypass may be a simple and useful approach for treating MAS if it is not necessary to reconstruct the renal artery or visceral artery.     

Renal artery stenosis

Among the indications for renal artery revascularization, either surgical or endovascular, in patients with renal artery stenosis are poorly controlled hypertension, ischemic nephropathy (preservation of renal function), or recurrent episodes of "flash" pulmonary edema and congestive heart failure. Pharmacologic treatment is the first-line therapy to control blood pressure. If the disease is unilateral, the blood pressure regimen should include an angiotensin-converting enzyme inhibitor. Guidelines published in the Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of high blood pressure should be followed. Revascularization is recommended if patients have at least 75% stenosis of one or both renal arteries, combined with resistant or poorly controlled hypertension; recurrent flash pulmonary edema; dialysis-dependent renal failure resulting from renal artery stenosis; chronic renal insufficiency and bilateral renal artery stenosis; or renal artery stenosis to a solitary functioning kidney. To treat fibromuscular disease of the renal arteries, percutaneous transluminal angioplasty is the revascularization procedure of choice. Ex vivo surgical repair of the renal artery may be required if there is significant branch renal artery stenosis. To treat atherosclerotic renal artery stenosis, the revascularization procedure of choice is percutaneous transluminal angioplasty and stent implantation, especially if there is concomitant ostial or proximal renal artery disease. Surgical revascularization is performed if concomitant aortic surgery is required, such as for abdominal aortic aneurysm.     

Successfully treated "accelerated" renovascular hypertension with intravascular stenting.

A 76-year-old man developed progressive renal dysfunction with refractory hypertension. Bilateral renal artery stenosis due to atherosclerosis was revealed. Both the hypertension and renal dysfunction were improved by percutaneous transluminal renal angioplasty with stenting. Based on the rapidly progressive elevation of plasma renin activity and the improvement of both renal dysfunction and hypertension after stenting, this was considered a case of "accelerated" renovascular hypertension. There have been an increasing number of patients with bilateral renal artery stenosis due to atherosclerosis. The present case reminds us that a rapid progression of renal dysfunction suggests, in addition to besides rapidly progressive glomerulonephritis with crescent formation, bilateral renal artery stenosis, the incidence of which is on the rise. In the present case, angioplasty with stenting was effective for blood pressure control and preservation of renal function.     

Page kidney: Rare cause of acute kidney injury after complicated renal artery angioplasty

The authors present a case of a patient who experienced a rare complication after attempted renal angioplasty and stenting, Page kidney. This patient presented with new onset hypertension secondary to bilateral renal artery stenosis and was referred for revascularization given hypertension refractory to medical management. The right renal artery underwent successful angioplasty and stenting; however, the left renal artery experienced recoil stenosis. Post‐procedure the patient developed acute kidney injury secondary to Page kidney from subcapsular and extracapsular hematoma. This was managed conservatively with transfusions and the hematoma and acute kidney injury self‐resolved over the next 4 months. This case highlights the importance of revascularization for refractory hypertension secondary to hemodynamically significant bilateral renal artery stenosis, the rare complication of Page kidney with attempted revascularization of renal artery stenosis and the involvement of a hypertension specialist in the decision of revascularization of renal artery stenosis.     

Revascularization of total renal artery occlusion by angioplasty and stent placement

Revascularization of renal artery stenosis for the treatment of hypertension is an established procedure. In selected clinical scenarios, successful revascularization procedures may preserve or restore renal function. We present a 66-year-old man with secundary hypertension and deteriorating renal function caused by bilateral atherosclerotic renal artery disease (complete obstruction of the left renal artery and subocclusive stenosis of the right) in which blood pressure was successfully controlled and renal function improved and maintained steady after bilateral percutaneus transluminal angioplasty and renal artery stenting.     

Renal insufficiency after administration of captopril in renal artery stenosis with a single kidney or bilateral stenosis is not compulsory

Acute renal failure has been reported during captopril therapy of hypertension due to renal artery stenosis with a single kidney or bilateral renal artery stenosis. Under low perfusion pressures inhibition of the renin-angiotensin system could disturb the autoregulation, decrease efferent arteriolar resistance and lead to a critical decrease in glomerular filtration. Renal function tests were repeated in a patient with hypertension due to 90 p. 100 renal artery stenosis with a single kidney, before and after captopril administration (sodium intake 100 mmol/24 h). (table; see text) Identical results have also been observed in a patient with bilateral renal artery stenosis. Both patients presented high risk renal haemodynamic states. The control of systemic blood pressure and the fall in filtration fraction were not associated with a critical, immediate or short term fall in glomerular filtration. The isolated administration of captopril is therefore not systematically contra-indicated in these two clinical situations.     

Atherosclerotic renal artery disease

Atherosclerotic renal artery stenosis may present with hypertension, renal failure (ischemic nephropathy), or congestive heart failure. The prevalence of renal artery stenosis is increasing in patients with other manifestations of atherosclerosis. The diagnosis is being made more frequently due to better screening tests such as duplex ultrasound and magnetic resonance angiography. Renal artery stenosis is discovered incidentally during imaging studies performed for other reasons. Revascularization should be performed using angioplasty and stenting in patients who have hypertension that cannot be adequately controlled with medications, in patients with severe bilateral renal artery stenosis or stenosis to a solitary functioning kidney and in patients with congestive heart failure when no other clear cut cause can be found.     

Coexistence of atherosclerotic renal artery stenosis with primary hyperaldosteronism

The discovery of two forms of secondary hypertension in the same patient is unusual and suggests similar pathophysiological mechanisms, a predisposition to one type in the presence of the other or a chance occurrence. We describe two patients with renal artery stenosis who after successful correction of the stenotic lesions were discovered to have primary hyperaldosteronism associated with bilateral adrenal hyperplasia. Initially prior to revascularisation of the renal artery stenosis, the diagnosis of primary hyperaldosteronism was not evident. Both patients were subjected to further diagnostic evaluation after the appearance of hypokalaemia in one patient and continued resistant hypertension in both patients. The addition of spironolactone therapy reduced blood pressure impressively in both patients. Clinicians should be aware of the possibility that these two forms of secondary hypertension may be present in the same patient and that optimal blood pressure control requires diagnostic assessment and intervention for both disorders.     

支架置入术联合自体肾移植术治疗双侧肾动脉狭窄1例并文献复习

目的:评估支架置入术联合自体肾移植术治疗肾血管性高血压的疗效。方法:顽固性高血压患者1例,经血管造影证实为双侧肾动脉显著狭窄,左肾动脉起始部70%~80%狭窄,行肾动脉支架置入术(PTRAS),右肾动脉起始部90%狭窄,因狭窄部紧靠右肾动脉起始部,而且伴有显著的狭窄后扩张,故未行PTRAS,而采用自体肾移植术。结果:经左肾动脉行支架置入术后,血压控制仍不满意,继而行右侧自体肾移植术,术后停服所有降压药物,血压能维持在正常水平。结论:在双侧肾动脉显著狭窄时,采用支架置入术联合自体肾移植术是合理及有效的治疗手段。     

Ischemic nephropathy in an elderly patient

Congestive heart failure often occurs in patients with bilateral renal artery stenosis. Recently, Jacobson and Breyer, and Jacobson introduced the term "ischemic nephropathy", which implies critical bilateral involvement or global ischemia. Ischemic nephropathy is not only a cause of hypertension but also an important cause of end-stage renal disease. However, the aging kidney often show that the renal artery does not demonstrate stenosis of the main trunks, but stenosis of an atherosclerotic branch. We present a case of multiple atherosclerotic peripheral renal arteries, which might have caused ischemic nephropathy in an elderly hypertensive patient with advanced atherosclerosis.