Regarding hypertension, there are two conditions that need to be taken seriously, one is the development of peripheral arterial disease and the other is refractory hypertension.
1. In hypertensive patients, why does peripheral arterial disease appear? What should I do once it appears?
Want to know why it appears? Understanding the pathological effect, it is natural to understand.
Hypertension accelerates the atherosclerotic process of elastic and muscular arteries.
Continuous elevation of blood pressure leads to changes in the structure and function of peripheral arteries, acceleration of atherosclerosis, and gradual progression to peripheral arterial disease.
Therefore, peripheral arterial disease is one of the target organ damages of hypertension.
In hypertensive patients, is there a high incidence of peripheral artery disease?
Peripheral artery disease (PAD) is a common manifestation of systemic atherosclerosis.
According to foreign epidemiological surveys, its prevalence is 3%-10% in the general population and 15%-20% in elderly people over 70 years old. In China, the prevalence is 2-4% in the general population and up to 16.4% in people over 60 years old.
It is even higher in patients with combined risk factors such as hypertension, diabetes and metabolic syndrome. Hypertension is present in about half of patients with peripheral artery disease (PAD) and increases the risk of cardiovascular events and death.
When combined with peripheral artery disease, what can be done to lower blood pressure?
Calcium channel blockers (CCB) and RAS inhibitors such as angiotensin-converting enzyme inhibitors (ACEI) or ARBs (angiotensin receptor antagonists), which lower blood pressure while also improving endothelial function in diseased vessels, should be used first.
Selective β1-blockers are effective in the treatment of hypertension combined with peripheral arterial disease (PAD), generally do not increase the resistance of diseased vessels, and have a preventive effect on coronary events, and are therefore not contraindicated.
Diuretics will reduce blood volume and increase blood viscosity, and are generally not recommended.
2, the definition of refractory hypertension, how to screen, principles of treatment, etc. need to know
(1) What is refractory hypertension?
Refractory hypertension (RH) is called when the blood pressure value is still above the target level in the office and outside the office (including home blood pressure or ambulatory blood pressure monitoring) after at least 4 weeks of treatment with tolerable and reasonable doses of 3 antihypertensive drugs (including a thiazide diuretic) based on lifestyle improvement, or when at least 4 drugs are needed to bring the blood pressure to the target.
(2) How is screening done clinically?
Determining whether a patient has refractory hypertension (RH) often requires the use of out-of-office blood pressure measurements (home blood pressure measurements and ambulatory blood pressure monitoring) in conjunction with the use of white coat blood pressure effects as well as pseudohypertension.
To look for causes and coexisting disease factors affecting poor blood pressure control, these include the following.
– The more common cause is poor patient compliance with treatment (failure to adhere to medication).
– Inappropriate selection and use of antihypertensive drugs (unreasonable drug combinations, inadequate doses of drugs used).
– The use of antagonistic antihypertensive drugs, including oral contraceptives, cyclosporine, erythropoietin, glucocorticoids, NSAIDs, antidepressants, cocaine and certain herbal medicines (e.g., licorice, ephedra).
– Other influencing factors are poor lifestyle, obesity, volume overload (inadequate diuretic therapy, high salt intake, progressive renal insufficiency).
– Or certain coexisting disease conditions such as diabetes, dyslipidemia, chronic pain, and chronic insomnia and anxiety.
(3) How is refractory hypertension managed?
The diagnosis of RH should be determined by a qualified hypertension specialist.
Advocate for out-of-office blood pressure measurement (home blood pressure and ambulatory blood pressure), effective communication with the patient, and concern for the patient’s long-term medication compliance.
Also try to eliminate influencing factors, mainly obesity, metabolic disorders, excessive sodium and salt intake and other poor lifestyle habits.
In terms of drug treatment, adjust the antihypertensive combination scheme, firstly check whether the composition of the multi-drug combination scheme is reasonable, it is recommended to choose the conventional dose of RAS inhibitor + CCB + thiazide diuretics, also consider increasing the dose of each drug according to the patient’s characteristics and tolerability, and the full dose should be reached.
If the treatment effect is still unsatisfactory, a fourth antihypertensive drug can be added according to patient characteristics. The choice can be made among aldosterone receptor antagonists, β-blockers, α-blockers or sympathetic depressants, but the principle of individualized treatment still needs to be applied.
References
[1] Revision Committee of the Chinese Guidelines for the Prevention and Treatment of Hypertension. Chinese guidelines for the prevention and treatment of hypertension (2018 revised edition) [J]. Chinese Journal of Cardiovascular Diseases,2019,24(1):47-48.
[2]by Fan Shaoguang,Liu Meilin. Hypertension and target organ damage [M]. Beijing:Science and Technology Literature Press,2017(10):189-193.