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。     

高血压 (3)继发性高血压的鉴别诊断和治疗(续2)

继发性高血压是病因明确并可通过祛除病因而治愈或缓解的高血压,常见于青中年。常见的继发性高血压原因包括肾实质性疾病、肾动脉狭窄、肾上腺疾病以及阻塞性睡眠呼吸暂停等。详细的病史采集、体格检查、影像学检查及实验室检查可满足继发性高血压的诊断与鉴别诊断需要。继发性高血压的治疗主要包括药物降压治疗以及针对病因的手术与非手术治疗。     

肾上腺疾病性高血压

肾上腺疾病是继发性高血压的重要病因，大部分肾上腺疾病性高血压可通过服用药物准备后行手术治疗，使高血压获得好转或治愈，因此正确认识及治疗。肾上腺疾病性高血压有重要意义。嗜铬细胞瘤和原发性醛固酮增多症为较常见的肾上腺疾病性高血压，其患病率在近年来有上升趋势，本文对这两种疾病的临床表现、实验室检查、定性、定位诊断、治疗及预后进行了较详细的综合介绍。     

肾上腺疾病性高血压

肾上腺疾病是继发性高血压的重要病因,大部分肾上腺疾病性高血压可通过服用药物准备后行手术治疗,使高血压获得好转或治愈,因此正确认识及治疗肾上腺疾病性高血压有重要意义。嗜铬细胞瘤和原发性醛固酮增多症为较常见的肾上腺疾病性高血压,其患病率在近年来有上升趋势,本文对这两种疾病的临床表现、实验室检查、定性、定位诊断、治疗及预后进行了较详细的综合介绍。     

难治性高血压的诊疗进展

难治性高血压(RH)是一种严重影响人们身体健康的特殊高血压类型。RH的影响因素有很多，包括血压测定操作规范、患者依从性、白大衣效应、继发性高血压等。近年来，RH靶器官损害及相关心脑血管疾病的发生率显著升高。因此，早期识别和诊断RH,选择有效的降压方案，对于改善RH患者的预后具有重要意义。本文针对RH目前的诊疗进展进行综述，以期为临床RH的诊疗提供理论参考。     

2023年《中国高血压防治指南》更新临床实践

高血压不仅仅是目前中国患病人数最多的慢性非传染性疾病,同时也是导致城乡居民心血管疾病死亡、致残的最重要危险因素。2018年我国成人高血压患病率处于下降趋势,但高血压患者的知晓率、治疗率和控制率已取得较好成绩,但总体仍处于较低的水平。因此,对于高血压的诊断、启动降压治疗时机、继发性高血压诊治、特殊人群高血压诊治都需要规范。我国2022年更新《中国高血压临床实践指南》,2023年更新《中国高血压防治指南》,对于临床实践有指导作用,但仍有一些问题需进一步探讨。     

继发性高血压的诊断和处理要点

高血压是最常见的心血管疾病,其中绝大多数是原发性高血压,继发性高血压约为5％。由于继发性高血压的发病和处理有特殊性,故本文着重概述由环孢素、妊娠、肾动脉狭窄引起的继发性高血压的处理。 1 环孢素引起的高血压 环孢素是目前器管移植中常用的免疫抑制剂,小剂量也用于自身免疫性疾病的治疗。虽然环孢素临床治疗效果较好,但却有一个严重的不     

青年高血压:病因学,靶器官损伤和治疗

背景青年高血压可导致早发心脑血管疾病并增加死亡率和致残率。但在发展中国家,针对青年人高血压的研究尚少。亦没有专门针对青年人高血压患者的防治指南。方法:入选2002年至2008年于阜外医院就诊,年龄16-30岁之间,于门诊诊断为药物难治性高血压或者高血压原因待查的患者,回顾性分析这些患者的病因学特点,抗高血压药物的使用以及靶器官的损伤。结果:共有309例患者入选,其中原发性高血压患者占59.9%(185/309),继发性高血压患者占38.8%(120/309)。肾血管性高血压是继发性高血压最常见的原因,而大动脉炎是肾血管性高血压最常见的致病原因。在原发性高血压患者中,57.8%的患者合并一种以上的代谢综合症,较继发性高血压患者明显增多(9.2%,p0.01),而两组患者靶器官损伤的比例没有显著差异(32.4%vs29.2%,p0.05).药物抵抗性高血压高达55.7%(172/309)。继发性高血压,肥胖,利尿剂的使用不足是导致药物抵抗性高血压最常见的原因。结论:在小于30岁的青年高血压患者中,有一半以上的患者具有高血压的继发性因素,针对这些继发疾病进行积极地治疗可有效治愈青年患者的高血压。在青年原发性高血压患者中,代谢综合症包括肥胖,糖尿病,高脂血症的发病率很高,这加重了患者靶器官的损伤并导致药物抵抗性高血压的产生。     

继发性高血压的24小时动态血压特点及意义

目前 ,无创性动态血压监测 (ambulatorybloodpressuremonitoring,ABPM)技术已广泛应用于临床高血压病的诊断和治疗 ,它较偶测血压更能准确反映患者的 2 4小时血压波动规律及范围。国外报道继发性高血压 (SH)血压昼夜节律与原发性高血压 (EH)不同 ,而国内少见有类似报道。本文对 40例继发性高血压和 40例原发性高血压患者的动态血压资料进行对比分析 ,探讨两者的血压变化特点及是否存在白昼与夜间差异 ,以及ABPM在这两类疾病鉴别诊断中的价值。1　资料和方法1.1　临床资料 :从 2 0 0 0年 6月至 2 0 0 2年 6月期间住院病人中抽取确诊 (根…     

肾血管性高血压的诊断与治疗现状

肾血管性高血压（RVH）是一种最常见的继发性高血压。目前,它的诊断和治疗方法仍存在争议。新近发展起来的筛选检查包括卡托普利肾动态显像（CRS）、彩色多普勒超声检查、磁共振血管成像（MRA）、肾动脉血管造影和三维重建（CTA）具诊断灵敏度和特异度高,对RVH的筛选和诊断有重要意义。目前国内外缺少大规模远期随机临床试验说明药物治疗、介入治疗和手术治疗的疗效差异以及对预后的影响有何不同。     

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.     

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.     

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.     

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 .     

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。     

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.