Resistant hypertension

Introduction Most hypertensive patients can be controlled to a satisfactory level of blood pressure after antihypertensive drugs, while a few hypertensive patients continue to increase their diastolic blood pressure despite the combination of larger doses of drugs, maintaining at 15.2 kPa (115 mm). Hg) or more is called refractory hypertension.

Cause

The cause of refractory hypertension:

The cause of refractory hypertension is more complicated. Generally, the reasons should be investigated from the following aspects.

(1) Improper diet Some hypertensive patients are caused by improper diet. That is, after suffering from hypertension, do not pay attention to control diet, such as eating and drinking, tobacco, alcohol, sugar, fatty meat, animal internal organs, etc., which aggravate arteriosclerosis, affecting blood vessel elasticity, causing vasospasm, blood pressure It is difficult to live high, so the effect of taking antihypertensive drugs is not good.

(2) Improper use of drugs, neglecting the comprehensive treatment of drugs, is often the cause of long-term treatment of hypertension, so high blood pressure patients should pay attention to the combination of drugs. At the same time, we should also pay attention to the use of drugs, stop the drug when it is not visible, or give up treatment because of the long-term treatment of blood pressure, patients with refractory hypertension often have to take medicine for life.

(3) Insufficient weight loss For obesity-type hypertension, the degree of obesity is often balanced with the increase in blood pressure. If such hypertensive patients rely solely on antihypertensive drugs instead of losing weight, blood pressure drops are often unsatisfactory, so this type of In addition to adhering to antihypertensive therapy, patients should also pay attention to weight loss.

(4) Poor mental health The increase in blood pressure is closely related to poor mental state. Because of emotional instability, the sympathetic nerve is in a state of tension, which causes the secretion of catecholamines in the body to increase, the blood vessels are in a contracted state, and the blood pressure is not cured for a long time. Hypertensive patients should pay attention to self-mediation, keep a happy mood, and overcome impatience.

(5) Excessive exercise Some hypertensive patients do not like activities, exercise is too small, eat sleep, sleep, eat, rely solely on drugs to reduce blood pressure, blood pressure is not cured for a long time, therefore, hypertensive patients should strengthen physical exercise. Sports activities can not only reduce blood pressure, but also remove fat and lose weight, regulate psychological balance, and improve mental stress.

an examination

Related inspection

Blood routine dynamic blood pressure monitoring (ABPM)

Diagnosis of refractory hypertension:

Most hypertensive patients can be controlled to a satisfactory level of blood pressure after antihypertensive drugs, while a few hypertensive patients continue to increase their diastolic blood pressure despite the combination of larger doses of drugs, maintaining at 15.2 kPa (115 mm). Hg) above.

Differential diagnosis

Differential diagnosis of refractory hypertension:

First, essential hypertension (hypertension)

The etiology of essential hypertension is not yet clear. Epidemiological investigations have shown that this disease has a certain relationship with the intake of salt, obesity, lack of certain nutrients, genetics, occupation, and environment. The incidence rate of this disease is higher in rural areas than in rural areas, and higher in the north than in the south. With the increase of age, the incidence rate of females is lower than that of males before menopause, but higher than that of males after menopause.

Hypertension has a slow onset of clinical disease and is asymptomatic in the early stage. Even when it is found during physical examination, a few may have symptoms such as headache, dizziness, vertigo, tinnitus, insomnia, fatigue, etc., but the presence or absence of symptoms or blood pressure levels are not necessarily In a positive proportion, severe cases can be secondary to hypertensive crisis or hypertensive encephalopathy (see above), often accompanied by heart, brain, kidney and other important organ damage, and even cerebral hemorrhage, heart failure, uremia and so on. Clinical diagnosis is to exclude secondary hypertension.

Second, secondary hypertension

(1) Renal hypertension

1, acute glomerulonephritis (acute nephritis) acute nephritis more common in streptococcal infection, staphylococcus, pneumococcus. Salmonella typhimurium and certain viral infections can also cause the disease. Its clinical features are: 1 more common in children; 2 history of pathogenic microorganisms may occur in l-3 weeks before onset; 3 often with oliguria (hematuria onset, urine) The liquid can be washed water (alkaline urine) or soy sauce (acidic urine); 4 edema is very common, the light manifests as morning eyelid edema, heavy when it can affect the whole body; 5 most with high blood pressure, and Often transient (1 to 2 weeks); moderate (when the amount of urine increases, blood pressure begins to decline L. If blood pressure continues for 1-2 weeks without falling or orphan P> 26.7kPa (200 mmHg), it indicates that the condition is serious, a few A sudden increase in blood pressure can also lead to heart failure or hypertensive encephalopathy. The cause of hypertension in acute nephritis is mainly related to the accumulation of sodium and sodium in the body and increased renin secretion. 5 Urine examination with erythrocytosis and mild to moderate proteinuria Characteristic, there may be leukocytosis and granular cast. Urinary fibrin degradation products (FDP) increased; 7 serum complement C3 decreased, streptococcal infection after nephritis anti-streptolysin O (ASO) positive; 3 course Self-limited (4-8 weeks) most prognosis is good.

The disease should be distinguished from the acute exacerbation of chronic glomerulonephritis, IgA nephropathy, and progressive glomerulonephritis. Acute exacerbation of chronic glomerulonephritis is more common in young and middle-aged patients. In the past, there was often a history of repeated edema or proteinuria. This symptom often appeared within 1 week after the pre-infection, and the blood pressure increased significantly and remained stable and stable, often accompanied by serum clearance. Protein loss, anemia, and obvious renal function (especially glomerular function) damage; although kidney disease is often caused by streptococcal infection, and has hematuria or proteinuria, but its incubation period is short (a few hours after infection) The sera of the onset of human disease are elevated, and the complement C3 is normal. The identification of patients with difficulty depends on renal biopsy; the onset of acute nephritis is very similar to acute nephritis, but the former progresses rapidly, and patients often show uremia in a few days. The increase is also obvious, and the treatment response is poor.

2, chronic glomerulonephritis (chronic nephritis) chronic nephritis is a chronic progressive glomerular damaging disease caused by a variety of reasons, is also the most common cause of secondary hypertension. Only a small number of cases are related to nephritis after acute streptococcal infection, and most of them are the result of the chronic development of primary glomerular disease. Patients often present with varying degrees of hypertension, edema, proteinuria, hematuria, and impaired renal function (the manifestations of nephritic syndrome). A small number of patients are concealed, and kidney atrophy and uremia are found. The rise of blood pressure caused by chronic nephritis is often persistent, and the diastolic blood pressure is mainly elevated. The fundus examination may also have retinal arterioles tortuosity, sputum, arteriovenous cross compression or even bleeding, exudation, etc. Clinical attention and late stage Renal damage caused by hypertension is differentiated from patients with extensive chronic nephritis (especially hypertension). The age of onset is mild (usually less than 40 years old); nephritic syndrome is obvious, and edema, proteinuria, hematuria occur at the same time or earlier than hypertension. Renal dysfunction occurs early and often glomerular dysfunction; heart enlargement is not obvious; anemia often occurs in the late stage. Hypertensive patients have a higher onset age (usually after the age of 40); hypertension occurs many years before the urine changes; blood pressure rises significantly; renal function damage occurs later and early often with tubular dysfunction @Increased); heart enlargement; no anemia (except for late uremia).

3, kidney disease with kidney disease is based on the main immunoglobulin deposition in the glomerular mesangial area characterized by chronic glomerular disease, clinical often with simple hematuria as the main performance, occurs in children and youth, male for the Lord. Most patients have a history of respiratory or digestive tract infection before onset, but the incubation period is short (a few hours to several days, often manifested as sudden onset of hematuria (general hematuria or microscopic hematuria may have nephritis syndrome (hypertension, Edema, proteinuria, hematuria and renal dysfunction, or nephrotic syndrome (large amounts of proteinuria, high edema, hypoalbuminemia, and hyperlipidemia). The condition can be repeated, but most of the prognosis is good. Immunopathological examination after renal biopsy.

4, interstitial nephritis interstitial nephritis is caused by a variety of causes of renal interstitial tubule lesions as the main manifestation of the syndrome, including infection, drug allergy, toxic damage (chemical or heavy metal poisoning), immune damage Physical damage is afraid of radiation nephritis L blood circulation disorder. Clinical acute and slow type, acute patients are often after drug allergy, manifested as chills, fever, rash, oliguria, proteinuria, urinary leukocytosis, etc., except for a small number of patients with acute renal failure, generally rarely caused hypertension. Symptoms of chronic patients are concealed, patients can have no discomfort for a long time, but urine routine examination has red blood cell count and protein positive, with the progress of the disease gradually appear hypertension, anemia and nocturia. Renal tubular dysfunction such as decreased relative density of urine. X-ray or ultrasonography showed that the patient's kidneys were reduced in size and the surface was uneven. This disease should be distinguished from pyelonephritis. Patients with pyelonephritis often have different degrees of urinary tract irritation. The urine routine is mainly caused by white blood cells or pus, and urinary bacteria culture can find pathogens. Antibiotic treatment is effective. However, clinical interstitial nephritis and pyelonephritis can be combined.

5, chronic pyelonephritis Chronic pyelonephritis is a chronic inflammation caused by pathogens (bacteria, fungi, protozoa or viruses) directly invading the renal pelvis and renal pelvis, which occurs in women, especially women of childbearing age. Pathogenic bacteria are most common in Escherichia coli. Ascending infection is the most common route of infection/bed performance. Although it can also have symptoms of systemic infection (slight fatigue, low fever, joint pain, X urinary tract irritation symptoms (frequent urination, urgency, dysuria, Low back pain) and urinary leukocytosis three major manifestations, but generally atypical, urinary bacteriological test positive is an important basis for diagnosis. Chronic pyelonephritis caused by hypertension is only seen in the late stage of the disease, the renal parenchyma suffered severe damage or even uremia, at this time Intravenous pyelography can be seen in the renal pelvis and renal pelvis deformation and stenosis, the two kidneys vary in size and uneven shape, renal function damage is mainly caused by tubule function damage. When uremia occurs and the clinical manifestations of chronic nephritis are similar, should pay attention to Identification. Chronic nephritis caused by repeated edema for many years, history of hypertension, urinary protein content and often accompanied by hypoalbuminemia, urinary examination of leukocytosis is not significant, glomerular dysfunction is more important than renal tubules Urine bacteriological examination was negative.

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