经“子母”导管行去肾交感神经治疗顽固性高血压二例

目的 探讨经“子母冶导管行肾动脉交感神经治疗顽固性高血压的方法及疗效。方法 2例顽固性高血压患者,于局麻下使用7F肾动脉指引导管套5F消融导管对其行经导管去肾交感神经术,螺旋式消融肾动脉内膜4~ 6个点,术中消融指标：每点消融时间累积120 s,消融功率8 W,消融阻抗150 ~250 赘,消融温度45益。结果 2例血压由术前170 /100,175/98 mmHg降至术后出院时的130/82,134/84 mm Hg,术后4个月随访期间平均血压分别为130/82,134/84 mm Hg。 2例患者术后降压药的用量和种类减少。结论 使用“子母冶导管行经导管去肾交感神经术治疗顽固性高血压安全、有效。     

Orthostatic function after renal sympathetic denervation in patients with resistant hypertension

Introduction

Catheter-based renal denervation (RDN) reduces local and whole-body sympathetic activity and blood pressure (BP) in patients with resistant hypertension. However, safety concerns exist concerning the development of orthostatic dysfunction after RDN.

Methods and results

In 36 patients (65 ± 7.6 years, 75% male) with resistant hypertension (office BP 162 ± 24/91 ± 14 mm Hg) treated with 4.8 ± 1.7 antihypertensive drugs, tilt table testing (TTT) was performed before and three months after RDN. Response to RDN was defined as a reduction in office systolic BP (SBP) ≥ 10 mm Hg three months after RDN. Responders (n = 26; 72.2%) and non-responders (n = 10; 27.8%) were evaluated separately. After RDN, office SBP and diastolic BP (DBP) were reduced by 29 ± 6.2/14 ± 3.6 mm Hg (p < 0.0001; p = 0.0002) only in responders. During TTT, SBP and DBP in supine position were only reduced in responders. Resting heart rate (HR) decreased in responders but not in non-responders by 5.9 ± 1.7 beats/min (p = 0.0016). Mean and minimal SBP were not altered during passive tilting. In the responder group, ?SBP was reduced in the initial phase of tilting. The adaptive increase of HR was preserved in both groups after RDN, while only in responders mean and minimal HR were reduced after passive tilting. Following drug provocation, mean and minimal SBP during all phases of passive tilting remained unchanged. ?SBP, ?HR and total number of (pre-)syncopes were neither influenced by RDN nor differing between responders and non-responders.

Conclusions

In patients with resistant hypertension, RDN reduced office BP, supine BP and HR during TTT without causing orthostatic dysfunction or (pre-)syncopes three months after treatment.     

Effects of renal sympathetic denervation on heart rate and atrioventricular conduction in patients with resistant hypertension

Background

Renal sympathetic denervation (RDN) reduces sympathetic activity and blood pressure (BP) in patients with resistant hypertension. The present study aimed to investigate the effects of RDN on HR and other electrocardiographic parameters.

Methods

136 patients aged 62.2 ± 0.8 years (58% male, BP 177 ± 2 / 93 ± 1 mm Hg) with resistant hypertension underwent RDN. BP and a 12-lead electrocardiogram (ECG) were recorded before, 3 months (n = 127), and 6 months (n = 88) after RDN.

Results

After 3 months (3 M) and 6 months (6 M), systolic BP was reduced by 25.5 ± 2.4 mm Hg (p < 0.0001) and 28.1 ± 3 mm Hg (p < 0.0001). HR at baseline was 66.1 ± 1 beats per minute (bpm) and was reduced by 2.6 ± 0.8 bpm after 3 months (p = 0.001) and 2.1 ± 1.1 bpm after 6 months (p = 0.046). Patients with HR at baseline between 60–71 bpm and ≥ 71 bpm had a reduction of 2.9 ± 7.6 bpm (p = 0.008) and 9.0 ± 8.6 bpm (p < 0.0001), respectively, whereas in patients with baseline HR < 60 bpm HR slightly increased after 3 months (2.7 ± 8.4 bpm; p = 0.035). Neither baseline HR nor change of HR correlated with the reduction of systolic BP. The PR interval was prolonged by 11.3 ± 2.5 ms (p < 0.0001) and 10.3 ± 2.5 ms (p < 0.0001) at 3 and 6 months after RDN, respectively.

Conclusions

Renal sympathetic denervation reduced heart rate and the PR interval as indicators of cardiac autonomic activity.     

经导管去肾交感神经治疗顽固性高血压——附两例报告

目的探讨经导管去肾交感神经治疗顽固性高血压的疗效。方法入选2例典型顽固性高血压患者,于全麻下使用Symplicity导管及射频仪对患者行经导管去肾交感神经术,螺旋式消融肾动脉内膜4～6个点,术中消融指标:每点消融时间2min,消融功率8W,消融阻抗250～350Ω,消融温度50～60℃。结果经过术后短期随访,两例患者血压控制良好。病例1患者血压由术后163/102mm Hg缓慢下降,术后第2天晨起血压125/90mm Hg,逐渐减少降压药,术后1个月行动态血压监测全天血压均值为129/82mm Hg。病例2患者血压由术后151/102mm Hg缓慢下降,术后第2天晨起血压120/78mm Hg,逐渐减少降压药,术后1个月行动态血压监测全天血压均值为130/81mm Hg。结论使用Symplicity导管及射频仪进行经导管去肾交感神经术,是治疗顽固性高血压有效的新方法。     

Renal hemodynamics and renal function after catheter-based renal sympathetic denervation in patients with resistant hypertension

Increased renal resistive index and urinary albumin excretion are markers of hypertensive end-organ damage and renal vasoconstriction involving increased sympathetic activity. Catheter-based sympathetic renal denervation (RD) offers a new approach to reduce renal sympathetic activity and blood pressure in resistant hypertension. The influence of RD on renal hemodynamics, renal function, and urinary albumin excretion has not been studied. One hundred consecutive patients with resistant hypertension were included in the study; 88 underwent interventional RD and 12 served as controls. Systolic, diastolic, and pulse pressure, as well renal resistive index in interlobar arteries, renal function, and urinary albumin excretion, were measured before and at 3 and 6 months of follow-up. RD reduced systolic, diastolic, and pulse pressure at 3 and 6 months by 22.7/26.6 mm Hg, 7.7/9.7 mm Hg, and 15.1/17.5 mm Hg (P for all <0.001), respectively, without significant changes in the control group. SBP reduction after 6 months correlated with SBP baseline values (r=-0.46; P<0.001). There were no renal artery stenoses, dissections, or aneurysms during 6 months of follow-up. Renal resistive index decreased from 0.691±0.01 at baseline to 0.674±0.01 and 0.670±0.01 (P=0.037/0.017) at 3- and 6-month follow-up. Mean cystatin C glomerular filtration rate and urinary albumin excretion remained unchanged after RD; however, the number of patients with microalbuminuria or macroalbuminuria decreased. RD reduced blood pressure, renal resistive index, and incidence of albuminuria without adversely affecting glomerular filtration rate or renal artery structure within 6 months and appears to be a safe and effective therapeutic approach to lower blood pressure in patients with resistant hypertension.     

Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months

Renal sympathetic hyperactivity is seminal in the maintenance and progression of hypertension. Catheter-based renal sympathetic denervation has been shown to significantly reduce blood pressure (BP) in patients with hypertension. Durability of effect beyond 1 year using this novel technique has never been reported. A cohort of 45 patients with resistant hypertension (systolic BP ≥160 mm Hg on ≥3 antihypertension drugs, including a diuretic) has been originally published. Herein, we report longer-term follow-up data on these and a larger group of similar patients subsequently treated with catheter-based renal denervation in a nonrandomized manner. We treated 153 patients with catheter-based renal sympathetic denervation at 19 centers in Australia, Europe, and the United States. Mean age was 57±11 years, 39% were women, 31% were diabetic, and 22% had coronary artery disease. Baseline values included mean office BP of 176/98±17/15 mm Hg, mean of 5 antihypertension medications, and an estimated glomerular filtration rate of 83±20 mL/min per 1.73 m(2). The median time from first to last radiofrequency energy ablation was 38 minutes. The procedure was without complication in 97% of patients (149 of 153). The 4 acute procedural complications included 3 groin pseudoaneurysms and 1 renal artery dissection, all managed without further sequelae. Postprocedure office BPs were reduced by 20/10, 24/11, 25/11, 23/11, 26/14, and 32/14 mm Hg at 1, 3, 6, 12, 18, and 24 months, respectively. In conclusion, in patients with resistant hypertension, catheter-based renal sympathetic denervation results in a substantial reduction in BP sustained out to ≥2 years of follow-up, without significant adverse events.     

不同剂量苯酚去肾交感神经术对自发性高血压大鼠血压影响

目的 探讨不同剂量苯酚去肾交感神经术对自发性高血压大鼠血压影响。方法 选用12周龄自发性高血压大鼠,肾动静脉局部涂抹不同剂量的苯酚,按照给药剂量分为4组：假手术组、0.5 ml苯酚组、1.0 ml苯酚组和1.5 ml苯酚组。大鼠适应性饲养1周,监测血压,1周后行苯酚化学腐蚀神经术,术后4周处死大鼠,采血,肾动脉及肾神经组织送检。采用ELISA法测定血浆去甲肾上腺素含量,肾动脉采用HE、Masson、PAS染色,肾神经采用免疫组化酪氨酸羟化酶染色及神经丝蛋白染色。结果 与假手术组相比,术后4周,1.0 ml苯酚组血压显著降低［（163.60±5.87）mm Hg比（193.70±6.07）mm Hg,P<0.01］,血浆去甲肾上腺素含量显著降低［（50.50±31.01）ng/L比（197.50±35.27）ng/L,P<0.01］;HE染色,肾动脉轻度损伤,神经中度损伤（3.46±0.30比0.44±0.30,P<0.01）,酪氨酸羟化酶低表达（0.51±0.30比2.58±0.30,P<0.01）,神经丝蛋白高表达（2.27±0.30比0.09±0.10,P<0.01）。结论 1.0 ml苯酚化学腐蚀神经术能够有效损伤肾神经,显著降低血压,且不造成肾动脉狭窄,其机制可能与肾交感神经酪氨酸羟化酶活性低有关。     

Salt intake and blood pressure response to percutaneous renal denervation in resistant hypertension

The effect of lowering sympathetic nerve activity by renal denervation (RDN) is highly variable. With the exception of office systolic blood pressure (BP), predictors of the BP‐lowering effect have not been identified. Because dietary sodium intake influences sympathetic drive, and, conversely, sympathetic activity influences salt sensitivity in hypertension, we investigated 24‐hour urinary sodium excretion in participants of the SYMPATHY trial. SYMPATHY investigated RDN in patients with resistant hypertension. Both 24‐hour ambulatory and office BP measurements were end points. No relationship was found for baseline sodium excretion and change in BP 6 months after RDN in multivariable‐adjusted regression analysis. Change in the salt intake–measured BP relationships at 6 months vs baseline was used as a measure for salt sensitivity. BP was 8 mm Hg lower with similar salt intake after RDN, suggesting a decrease in salt sensitivity. However, the change was similar in the control group, and thus not attributable to RDN.     

高血压合并阻塞性睡眠呼吸暂停综合征动态血压临床分析

目的:探讨高血压合并阻塞性睡眠呼吸暂停综合征动态血压的临床特点.方法:高血压合并阻塞性睡眠呼吸暂停综合征患者作为睡眠呼吸暂停组,单纯高血压患者作为高血压组,所入选的88例患者均行24h动态血压监测,比较两组患者24h动态血压的特点.结果:(1)睡眠呼吸暂停组较高血压组体重指数(BMI)和颈围及血清TC、TG和LDL-C...     

Influence of sleep apnea severity on blood pressure variability of patients with hypertension

Purpose

Obstructive sleep apnea (OSA) is a risk factor for the development of hypertension and cardiovascular disease. Apnea overloads the autonomic cardiovascular control system and may influence blood pressure variability, a risk for vascular damage independent of blood pressure levels. This study investigates the hypothesis that blood pressure variability is associated with OSA.

Methods

In a cross-sectional study, 107 patients with hypertension underwent 24-h ambulatory blood pressure monitoring and level III polysomnography to detect sleep apnea. Pressure variability was assessed by the first derivative of blood pressure over time, the time rate index, and by the standard deviation of blood pressure measurements. The association between the apnea–hypopnea index and blood pressure variability was tested by univariate and multivariate methods.

Results

The 57 patients with apnea were older, had higher blood pressure, and had longer duration of hypertension than the 50 patients without apnea. Patients with apnea–hypopnea index (AHI) ≥ 10 had higher blood pressure variability assessed by the standard deviation than patients with AHI < 10 during sleep (10.4?±?0.7 versus 8.0?±?0.7, P?=?0.02) after adjustment for age, body mass, and blood pressure. Blood pressure variability assessed by the time rate index presented a trend for association during sleep (P?=?0.07). Daytime blood pressure variability was not associated with the severity of sleep apnea.

Conclusion

Sleep apnea increases nighttime blood pressure variability in patients with hypertension and may be another pathway linking sleep abnormalities to cardiovascular disease.     

Renal sympathetic denervation suppresses postapneic blood pressure rises and atrial fibrillation in a model for sleep apnea

The aim of this study was to identify the relative impact of adrenergic and cholinergic activity on atrial fibrillation (AF) inducibility and blood pressure (BP) in a model for obstructive sleep apnea. Obstructive sleep apnea is associated with sympathovagal disbalance, AF, and postapneic BP rises. Renal denervation (RDN) reduces renal efferent and possibly also afferent sympathetic activity and BP in resistant hypertension. The effects of RDN compared with β-blockade by atenolol on atrial electrophysiological changes, AF inducibility, and BP during obstructive events and on shortening of atrial effective refractory period (AERP) induced by high-frequency stimulation of ganglionated plexi were investigated in 20 anesthetized pigs. Tracheal occlusion with applied negative tracheal pressure (NTP; at -80 mbar) induced pronounced AERP shortening and increased AF inducibility in all of the pigs. RDN but not atenolol reduced NTP-induced AF-inducibility (20% versus 100% at baseline; P=0.0001) and attenuated NTP-induced AERP shortening more than atenolol (27±5 versus 43±3 ms after atenolol; P=0.0272). Administration of atropine after RDN or atenolol completely inhibited NTP-induced AERP shortening. AERP shortening induced by high-frequency stimulation of ganglionated plexi was not influenced by RDN, suggesting that changes in sensitivity of ganglionated plexi do not play a role in the antiarrhythmic effect of RDN. Postapneic BP rise was inhibited by RDN and not modified by atenolol. We showed that vagally mediated NTP-induced AERP shortening is modulated by RDN or atenolol, which emphasizes the importance of autonomic disbalance in obstructive sleep apnea-associated AF. Renal denervation displays antiarrhythmic effects by reducing NTP-induced AERP shortening and inhibits postapneic BP rises associated with obstructive events.     

高血压合并阻塞性睡眠呼吸暂停综合征患者昼夜血压的变化

目的研究轻中度高血压合并阻塞性睡眠呼吸暂停综合征(OSAS)患者昼夜血压变化的特点。方法入选心功能(NHYA)Ⅰ级的轻中度高血压患者177例,经多导睡眠呼吸监测后,按睡眠呼吸暂停指数分为4组,单纯高血压组(A组)42例,高血压合并轻度OSAS组(B组)66例,高血压合并中度OSAS组(C组)25例和高血压合并重度OSAS组(D组)44例,进行24 h动态血压监测。结果 D组患者昼间和夜间血压水平明显高于A组(P<0.05,P<0.01),与A组比较,B、C和D组夜间舒张压显著升高(P<0.05,P<0.01)。夜间低血氧水平与醒时、醒后舒张压、昼间、夜间收缩压和舒张压呈负相关(P<0.05)。结论轻中度高血压合并OSAS患者的夜间舒张压更高,合并重度OSAS的高血压患者全天血压水平均明显高于单纯高血压患者,血压升高幅度与夜间低氧血症程度呈负相关。