CaseofRefractoryHypertensionControlledAfterAorticandMitralValveReplacementandCoronaryArteryBypassGraftingHypertensioncase-reportJuly01,:72(1),3–./HYPERTENSIONAHA..本文由“天纳”临床学术信息人工智能系统自动翻译点击文末“阅读原文”下载本文PDFIntroductionA78-year-oldblackmanpresentedtotheHypertensionClinicattheUniversityofAlabamaatBirminghamforuncontrolledbloodpressure(BP).HisBPremaineduncontrolled(automatedoffice,≥/85mm?Hg)fromAugusttoAugustinspiteofuseof6antihypertensiveagentsinadequatedoses(Figure1).Duringthistimeperiod,hisaveragesystolicBPwas.1mm?HgandaveragediastolicBPwas68.7mm?Hg.一名78岁的黑人男子因血压失控被送到伯明翰阿拉巴马大学的高血压诊所。年8月至年8月，尽管在适当剂量下使用了6种抗高血压药物，但他的血压仍然不受控制（自动化办公室，≥/85mmHg）（图1）。在此期间，他的平均收缩压为.1毫米汞柱，平均舒张压为68.7毫米汞柱。Figure1.Bloodpressure(BP)andantihypertensivemedicationsbeforeandaftersurgery.CABGindicatescoronaryarterybypassgrafting.Thepatientwason3antihypertensivemedicationsoninitialpresentationtoUniversityofAlabamaatBirminghamin,includinganangiotensinreceptorblocker(irbesartan),acalciumchannelblocker(amlodipine),andalong-actingthiazide-likediuretic(chlorthalidone).Spironolactonewasaddedasafourthantihypertensiveagent.Eventually,hydralazine—avasodilator—andclonidine—acentrallyactingsympatholytic—wereaddedasthefifthandsixthantihypertensiveagents.Thepatient’sBPremaineduncontrolledon6differentclassesofantihypertensivemedications(Figure1).年，患者在阿拉巴马大学伯明翰分校初次接受治疗时服用了3种抗高血压药物，包括血管紧张素受体阻滞剂（厄贝沙坦）、钙通道阻滞剂（氨氯地平）和长效噻嗪类利尿剂（氯吡酮）。螺内酯作为第四种降压剂加入。最后，第五和第六种抗高血压药分别加入了胼酞嗪（一种血管扩张剂）和可乐定（一种中枢作用的共病药）。患者的血压在6种不同类型的抗高血压药物中保持不受控制（图1）。ComorbiditiesComorbiditiesandsecondarycausesofhypertensionwereevaluatedbybiochemicalanalysisandimaging.通过生化分析和影像学评价高血压的合并症和继发性病因。BiochemicalAnalysisThepatientwasdiagnosedwithmildchronickidneydisease.Meanserumcreatininewas1.35mg/dLwithanestimatedglomerularfiltrationrateof58mL/minper1.73m2.Diabetesmellituswasexcluded(HbA1cwas5.5%),primaryaldosteronismwasexcludedastheplasmaaldosterone–reninratiowas30(plasmaaldosteronewas4ng/dL,andplasmareninactivitywas1.0ng/mLperhour),andpheochromocytomawasexcludedasplasmametanephrine(0.4nMol/L)andnormetanephrine(0.2nMol/L)werenotelevated.病人被诊断为轻度慢性肾病。平均血清肌酐为1.35mg/dl，估计肾小球滤过率为58ml/min/1.73m2。排除糖尿病（HbA1c为5.5%），排除原发性醛固酮增多症，因为血浆醛固酮-肾素比值30（血浆醛固酮4ng/dl，血浆肾素活性为1.0ng/ml/h），排除嗜铬细胞瘤为血浆去甲肾上腺素（0.4nmol/l），去甲肾上腺素（0.2nmol/l）不升高。RenalUltrasoundWithDopplerRenaldupleximagingshowednoevidenceofrenalarterystenosis.双肾显像显示没有肾动脉狭窄的迹象。TransthoracicEchocardiographThispatienthadnormalleftventricularsystolicfunction(leftventricularejectionfraction[EF],≥50%–55%),elevatedstrokevolume(SV;93mL),andsevereleftventriculardilation.Valvularlesionsidentifiedbytransthoracicechocardiograph(TTE)were：1.Moderate-to-severemitralvalveregurgitation:themitralvalvewasmyxomatousandthickened;theannuluswasdilated(5cmindiameter),andthejetwaseccentricallyandposteriorlydirected,whichcausedsystolicretrogradeflowintherightpulmonaryvein.TheE/Aratio(ratioofearly-to-lateventricularfillingvelocitiestoevaluatediastolicperformanceoftheheart)was1.5.2.Moderate-to-severeaorticvalveinsufficiency:theaorticvalvewasthickened,andthejetwaseccentricallydirectedtowardtheanteriormitralvalveleaflet.3.Mildtricuspidregurgitationandtracepulmonaryvalveregurgitation.患者左室收缩功能正常（左室射血分数[EF]，≥50%–55%），卒中量升高（SV；93ml），左室扩张严重。经胸超声心动图（TTE）确定的瓣膜病变：1.中度至重度二尖瓣反流:二尖瓣呈粘液瘤样增厚;扩张环(直径5cm)，射流偏心后向，引起右肺静脉收缩期逆行血流。E/A比值(评价心脏舒张功能的室性充盈早期与晚期的比值)为1.5。2.中度至重度主动脉瓣功能不全:主动脉瓣增厚，射流偏心向二尖瓣前叶。3.轻度三尖瓣反流及微量肺动脉瓣反流。LeftandRightHeartCatheterizationTheleftmainarteryhada60%distalcalcifiedstenosis;theleftanteriordescendingarteryhadan80%proximalcalcifiedstenosiswithdiffuse60%distalstenosis,andtheleftcircumflexarteryhadaproximal40%calcifiedstenosis.Therightcoronaryarteryhadaseverediffuse80%stenosis,andtheposteriordescendingarteryhada60%stenosis.Fillingpressureswerehigh:therightatrialpressurewas12mm?Hg;pulmonaryarterypressurewas42/21mm?Hgandthepulmonarycapillarywedgepressurewas24mm?Hg.左主动脉远端钙化狭窄60%，左前降支近端钙化狭窄80%，远端弥漫性狭窄60%，左回旋动脉近端钙化狭窄40%。右冠状动脉弥漫性狭窄占80%，后降支狭窄占60%。充盈压高：右房压12mmHg，肺动脉压42/21mmHg，肺毛细血管楔压24mmHg。Discussion:ManagingtheHypertensionDrCarey
hisisaveryinterestingcase.IwouldliketogobacktotheaveragesystolicanddiastolicBPsintheoffice.Itappearsthiswaspredominantlysystolichypertension,andtherewasarelativelylowdiastolicpressure.Iwouldlikeusalltoreflectthatapatientwithmajorcoronaryatheroscleroticdiseasemaybeatriskforamyocardialinfarctionwhenthediastolicpressuredropsbelowfillingpressure.So,onehastobeverycarefuluntildefinitivetherapyisachieved.凯里医生：这是一个非常有趣的病例。我想回到办公室里收缩压和舒张压的平均值。这似乎主要是收缩性高血压，舒张压相对较低。我希望大家都能反映出，当舒张压低于充盈压时，患有严重冠状动脉粥样硬化疾病的患者可能有心肌梗死的风险。所以，在获得明确的治疗之前，我们必须非常小心。DrPhillips:Eventhoughtheguidelinesgivetheopportunitytouseβ-blockers,Iwouldnotuseβ-blockersforthispatient.Iwouldnotgivehimallthattimeforfilling.Youaregivinghimtimetoraisehisleftventricularanddiastolicpressurewithallthataorticinsufficiencyandheisalreadydemonstratingthatheisnotabletotoleratethat,withregardtodiastolicfunction.Asacardiologistinasurgicalhospital,HoustonMethodist—thehomeofstilltheghostofMichaelDeBakey—Iwouldhaveprobablyhadhimintheoperatingroomacoupledaysago.菲利普斯博士：尽管指导方针给了使用β-阻滞剂的机会，但我不会为这个病人使用β-阻滞剂。我不会把所有的时间都给他。你给了他时间，让他在主动脉瓣关闭不全的情况下提高左心室和舒张压，他已经证明他在舒张功能方面不能容忍这种情况。医院的心脏病专家，休斯顿卫理公会是迈克尔·德巴基幽灵的家——我可能几天前就把他放在手术室了。ProfessorBursztyn:Iwouldliketoraiseanissuewiththeneedforsomeofthesecondaryhypertensionworkup.IfsomeonetakesanangiotensinconvertingenzymeinhibitororangiotensinIIreceptorblocker,asthispatientdid,andhasseverehypertension,thelikelihoodthatthefindingofrenalarterystenosiswillleadtoanyhelpfultherapeuticactionisnull,giventhatthisisthebestpredictionofsuccessfulrenalrevascularization.Pheochromocytomaisextremelyrare,ingeneral,andinparticular,attheageof78years,insomeonewhosehypertensionissomewhatjustified,and,Ithink,thisisnothelpful.Secondaryhyperaldosteronismiscertainlysomethingthatisimportantinthispatient.Iwouldlikealsotohaveaword,intermsofwhatarethebenefitsofaddinghydralazinetoahighdoseofamlodipine.Some30yearsago,whennifedipinewasanemergingproduct,mycolleaguesandmyselffound,asmanyothersdid,that30mgofnifedipinesurpassestheantihypertensiveefficacyofmgofhydralazine.Therefore,Ithink,inthiscontext,minoxidilmighthavebeenabetterchoice,giventhatheistakingaβ-blocker.Inaddition,heistakingthediuretic;therefore,someoftheexpectedsideeffectsofminoxidilcanbecounteracted.伯兹坦教授：我想提出一个问题，需要做一些继发性高血压检查。如果有人服用血管紧张素转换酶抑制剂或血管紧张素II受体阻滞剂，就像这个病人那样，并且患有严重的高血压，那么发现肾动脉狭窄会导致任何有帮助的治疗作用的可能性是无效的，因为这是肾血管重建成功的最佳预测。嗜铬细胞瘤是非常罕见的，一般来说，尤其是在78岁的时候，在某些人的高血压是合理的，我认为这是没有帮助的。继发性醛固酮增多症在这个病人中肯定是很重要的。我还想说一句，在高剂量氨氯地平中加入胼酞嗪有什么好处。大约30年前，当硝苯地平是一种新兴产品时，我和我的同事们发现，和其他许多人一样，30毫克的硝苯地平超过了毫克的胼酞嗪的降压效果。因此，我认为在这种情况下，米诺地尔可能是一个更好的选择，因为他正在服用β-阻滞剂。此外，他正在服用利尿剂；因此，米诺地尔的一些预期副作用可以抵消。DrCalhoun
hatisthereasonforpresentingthecaseatthispoint.Obviously,wewerenotcontrollinghisBP,inspiteofthe6medications;sowearelookingforfeedbackintermsofwhatwemighthavedonedifferently.Anecdotally,wedoseeadditionalbenefitaddinghydralazinetoadihydropyridinecalciumchannelblocker,intermsofBPcontrol,sothatisroutinelydoneinourclinic.卡尔霍恩博士：这就是目前提出这个病例的原因。显然，我们没有控制他的血压，尽管有6种药物；所以我们正在寻找反馈，我们可能做了不同的事情。有趣的是，在血压控制方面，我们确实看到了在二氢吡啶钙通道阻滞剂中添加胼酞嗪的额外好处，因此这在我们的临床中是常规的。Butbeforewegettotheresolution,IthinkProfessorSicawilladviseastowhatweshouldhavebeendoing.但在我们达成决议之前，我想西卡教授会建议我们应该做些什么。ProfessorSica:Echoingthe
