Angioplastie rénale : état des lieux en 2014

Atherosclerotic renal artery stenosis can cause ischaemic nephropathy and arterial hypertension. Renal artery stenosis (RAS) continues to be a problem for clinicians, with no clear consensus on how to investigate and assess the clinical significance of stenotic lesions and manage the findings. RAS caused by fibromuscular dysplasia is probably commoner than previously appreciated, should be actively looked for in younger hypertensive patients and can be managed successfully with angioplasty. Atheromatous RAS is associated with increased incidence of cardiovascular events and increased cardiovascular mortality, and is likely to be seen with increasing frequency. Many patients with RAS may be managed effectively with medical therapy for several years without endovascular stenting, as demonstrated by randomized, prospective trials including the cardiovascular outcomes in Renal Atherosclerotic Lesions (CORAL) trial, the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial. These trials share the limitation of excluding subsets of patients with high-risk clinical presentations, including episodic pulmonary edema and rapidly progressing renal failure and hypertension. Blood pressure control and medication adjustment may become more difficult with declining renal function and may prevent the use of angiotensin receptor blocker and angiotensin-converting enzyme inhibitors. The objective of this review is to evaluate the current management of RAS for cardiologists in the context of recent randomized clinical trials. There is now interest in looking more closely at patient selection for intervention, with focus on intervening only in patients with the highest-risk presentations such as flash pulmonary edema, rapidly declining renal function and severe resistant hypertension.     

Caractéristiques épidémio-cliniques de l’hypertension artérielle résistante du sujet noir africain

Introduction

Few studies in sub-Saharan Africa were interested in resistant hypertension. The objectives of this study were to determine the frequency of resistant hypertension in hypertensive black African population, and to describe its clinical and therapeutic features.

Patients and methods

From May 1, 2010 to May 31, 2012, we included consecutively hypertensive followed in two hospitals in the city of Ouagadougou, under antihypertensive treatment at optimum dose and observant. Patients whose blood pressure was uncontrolled despite a triple antihypertensive therapy at the optimal dose including a diuretic associated with dietary measures have received ambulatory blood pressure monitoring. Following this examination, patients whose blood pressure was ≥ 135/85 mmHg during the day and/or ≥ 120/70 mmHg at night were considered resistant hypertension. We investigated the cardiovascular risk factors as well as target organ damages. We combined spironolactone 50 mg in treatment when absence of contra-indication appreciated the evolution of blood pressure under this treatment. The measurement of plasma renin activity was not performed. Statistical analysis was performed using SPSS Version 17 for Windows.

Results

We included 692 patients with 14.6% of resistant hypertension. The average age of patients was 54.8 ± 11.1 years in the general population, 56.5 ± 11.8 years in the subgroup of non-resistant hypertension and 64.2 ± 5.4 years in the subgroup of resistant hypertension. The symptoms were represented by headache (11.9%), dizziness (9.9%) and chest pain (8.9%). Modifiable cardiovascular risk factors were dominated by dyslipidemia, diabetes and obesity/overweight. These risk factors were significantly more frequent in the subgroup of resistant hypertension. The global cardiovascular risk was high in 24.9% of cases in the general population, 22.5% in the subgroup of non-resistant hypertension and 38.6% in the subgroup of resistant hypertension. The target organ damages were significantly more frequent in the same subgroup of resistant hypertension. After addition of spironolactone, 21.8% of resistant hypertensive patients were controlled.

Conclusion

This study shows that resistant hypertension is common in black Africans. It is mostly subjects of the sixth decade, with limited economic income and living in rural areas. In the absence of contra-indication, spironolactone contributed to decrease the morbidity of this pathology.     

Artériopathie oblitérante des membres inférieurs et rééducation vasculaire : exemple d’un centre de rééducation cardiovasculaire

Supervised vascular rehabilitation exercises in specialized center are recommended by national guidelines and the benefits are demonstrated by many studies. It integrates global management of cardiovascular disease with risk factors modification, optimum medical treatment and extension assessment. We associate supervised vascular exercise program based on walk and specifics care, such as lymphatic drainage, reflex massage, electrotherapy and patient education.