Lancet:高血压顽固到总降不下来?小小微创手术帮您解决!

2021-05-22 MedSci原创 MedSci原创

RDN至少可在术后2个月内降低难治性高血压患者的血压。

2018年美国心脏协会(AHA)科学声明、2017年美国心脏病学会(ACC)/AHA高血压指南,以及2018年欧洲心脏病学会(ESC)/欧洲高血压学会(ESH)的声明将难治性高血压定义为:同时使用3种不同类别的降压药,血压仍高于目标值。

2018年AHA难治性高血压专家共识指出,继发性高血压是难治性高血压的主要原因之一,而在继发性高血压中,内分泌性疾病特别是肾上腺疾病引起的高血压占据相当大的比重。其中主要包括原发性醛固酮增多症(原醛症)、儿茶酚胺增多症、皮质醇增多症,这部分患者往往伴随持续性血压升高且难以控制,给患者带来的血管风险较大。

有人可能会说,加药不就可以解决难治性高血压么,例如醛固酮受体(MR)?2018年哈佛大学发表的一项回顾性分析显示,与年龄匹配及血压水平相似的原发性高血压患者相比,MR治疗的原醛症患者,如果肾素仍然受到抑制,其发生心血管事件心肌梗死卒中,因心力衰竭住院)的风险几乎高出3倍。

为此近年来,针对难治性高血压,除了生活方式干预和药物治疗外,器械治疗尤其是肾动脉去交感神经消融术(RDN)得到了高血压治疗领域广大临床医师越来越多的重视和关注。近日,国际RADIANCE-HTN协作组评估了RDN在对难治性高血压患者中的疗效和安全性,结果发表在《柳叶刀》Lancet杂志上。

研究人员在美国的28个中心和欧洲的25个中心进行了一项随机、国际、多中心、单盲、假对照的试验,纳入了18-75岁的患者,所有参与者服用了包括利尿剂在内的三种以上的降压药物,但血压仍高于140/90mmHg。符合条件的患者被换成每日一次的固定剂量的钙通道阻断剂+血管紧张素受体阻断剂+噻嗪类利尿剂的药物标准化治疗组合。

经过4周的标准化治疗后,白天流动血压≥135/85mmHg的患者随机分配(1:1)到RDN或假手术。研究的主要终点是在有意治疗人群中,2个月时白天流动收缩压的变化。安全性也在意向性治疗人群中进行了评估。

在2016.03.11-2020.03.10期间,989名参与者被纳入,136人被随机分配到RDN(n=69)或假手术(n=67),两组患者在2个月时对联合药物的依从性相似。总的来说,2个月时,比假手术相比,RDN能更有效地降低日间动态收缩压(−8.0 mm Hg vs -3.0 mm Hg,组间差异中值为-4.5mmHg)。

2个月时,RDN与假手术组术前(蓝)与术后(红)收缩压变化

同时,RDN也更有效降低了夜间动态收缩压(−8.3 mm Hg vs -1.8 mm Hg,组间差异中位数-3.9 mm Hg)、24小时动态收缩压(组间差异中位数-4.2 mm Hg),以及多个舒张压指标。而在有完整流动血压数据的患者中,两组的组间中位差异为-5.8mmHg,更为显著。

由此可见,RDN至少可在术后2个月内降低难治性高血压患者的血压。如果RDN手术的降压效果和安全性能够长期保持,则不乏成为药物降压的替代方法。

 

参考文献:

Ultrasound renal denervation for hypertension resistant to a triple medication pill (RADIANCE-HTN TRIO): a randomised, multicentre, single-blind, sham-controlled trial. https://doi.org/10.1016/S0140-6736(21)00788-1

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    2021-08-16 howi
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    2021-05-24 vera_1203
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    2021-05-22 14775a26m11暂无昵称

    去交感在有效无效之间反复横跳

    0

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    2021-05-22 goodbing

    顶刊就是不一样,质量很高,内容精彩!学到很多

    0

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    2021-05-22 长情

    好文一篇

    0

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