难治性高血压的监测与针对性治疗
http://www.100md.com
摘要 难治性高血压病人由于缺乏或不适当的治疗，经历一个从轻度高血压到中、重度高血压的进展过程，大小动脉重构促进高血压的进展和并发症的发生。本文归纳了难治性高血压的原因，高血压病人需要进行血压、高血压相关血管活性物质和血管重构的监测，分析难治性高血压的影响因素，采取有针对性的降压治疗方案，将会改变难治性高血压的治疗现状。
Monitoring and treatment of aiming at causes in refractory hypertension
Liao Yuhua
Insititute of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Chian
, http://www.100md.com
Refractory hypertension is a progressive process from mild hypertension to moderate, severe hypertension due to absence or inadequate treatment in patients with hypertension. The large and small artery remodeling accelerated the progression of hypertension and complication. The causes of refractory hypertension were summed up. It is necessary that the blood pressure, the vasoactive substance and vessel remodeling were detected in patients with hypertension. Careful, systematic evaluation of patients with refractory hypertension should identify condition and mechanisms of hypertension to targeted therapy. If a depressor plan of aiming at the causes of refractory hypertension was adopted, the treatment condition of refractory hypertension should be changed.
, 百拇医药
难治性高血压是指高血压病人经过足够剂量和合理的三种降压药联合治疗，包括利尿剂，三种药物均已用到几乎最大剂量，血压仍不能降到140/90mmHg以下；对于单纯收缩期高血压的老年人在类似的处理后，收缩压不能控制在160mmHg以下[1]。难治性高血压的发病率难以确定，据一些研究结果提示难治性高血压发病率为3%～29%[2-3]。
1难治性高血压的原因
1.1 血管重构和并发症：大小动脉重构促进高血压的进展和并发症的发生。难治性高血压大约在高血压人群中占5%以上，其发生率伴随着高血压严重程度的增加而上升。难治性高血压病人由于缺乏或不适当的治疗，经历一个从轻度高血压到中、重度高血压的进展过程[4]。
高血压时小动脉结构变化有2种形式：①向心性发育重构(inward eutrophic remodeling)，即血管外层和管腔减小、中层/管腔比值增加、中层的截面积不变；②肥厚性重构(hypertrophic remodeling)，即中层厚度侵犯管腔内，导致中层截面积和中层/管腔比值的增加。高血压时血管细胞增生、凋亡、炎症和纤维化等复合作用，增加细胞基质整联蛋白(integrin)和改变血管的几何形状，以致血管结构改变。基质金属蛋白酶和组织金属蛋白酶抑制剂之间的平衡失调可以促进胶原更新和细胞外基质改变，促进血管重构。长期血管收缩可以诱导血管平滑肌细胞围绕小血管腔排列，使收缩血管的结构被包埋，小血管重构的早期是一种适应性的过程，但最终变为适应不良和失代偿，促进高血压并发症的产生[5]。
在长期治疗的高血压病人中，靶器官损害与血压不能有效地控制有关。一组临床观察显示与血压控制的高血压病人比较，难治性高血压病人左心室肥厚增加(40% vs 12%, P, http://www.100md.com
Monitoring and treatment of aiming at causes in refractory hypertension
Liao Yuhua
Insititute of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Chian
, http://www.100md.com
Refractory hypertension is a progressive process from mild hypertension to moderate, severe hypertension due to absence or inadequate treatment in patients with hypertension. The large and small artery remodeling accelerated the progression of hypertension and complication. The causes of refractory hypertension were summed up. It is necessary that the blood pressure, the vasoactive substance and vessel remodeling were detected in patients with hypertension. Careful, systematic evaluation of patients with refractory hypertension should identify condition and mechanisms of hypertension to targeted therapy. If a depressor plan of aiming at the causes of refractory hypertension was adopted, the treatment condition of refractory hypertension should be changed.
, 百拇医药
难治性高血压是指高血压病人经过足够剂量和合理的三种降压药联合治疗，包括利尿剂，三种药物均已用到几乎最大剂量，血压仍不能降到140/90mmHg以下；对于单纯收缩期高血压的老年人在类似的处理后，收缩压不能控制在160mmHg以下[1]。难治性高血压的发病率难以确定，据一些研究结果提示难治性高血压发病率为3%～29%[2-3]。
1难治性高血压的原因
1.1 血管重构和并发症：大小动脉重构促进高血压的进展和并发症的发生。难治性高血压大约在高血压人群中占5%以上，其发生率伴随着高血压严重程度的增加而上升。难治性高血压病人由于缺乏或不适当的治疗，经历一个从轻度高血压到中、重度高血压的进展过程[4]。
高血压时小动脉结构变化有2种形式：①向心性发育重构(inward eutrophic remodeling)，即血管外层和管腔减小、中层/管腔比值增加、中层的截面积不变；②肥厚性重构(hypertrophic remodeling)，即中层厚度侵犯管腔内，导致中层截面积和中层/管腔比值的增加。高血压时血管细胞增生、凋亡、炎症和纤维化等复合作用，增加细胞基质整联蛋白(integrin)和改变血管的几何形状，以致血管结构改变。基质金属蛋白酶和组织金属蛋白酶抑制剂之间的平衡失调可以促进胶原更新和细胞外基质改变，促进血管重构。长期血管收缩可以诱导血管平滑肌细胞围绕小血管腔排列，使收缩血管的结构被包埋，小血管重构的早期是一种适应性的过程，但最终变为适应不良和失代偿，促进高血压并发症的产生[5]。
在长期治疗的高血压病人中，靶器官损害与血压不能有效地控制有关。一组临床观察显示与血压控制的高血压病人比较，难治性高血压病人左心室肥厚增加(40% vs 12%, P, http://www.100md.com