Treatment of secondary hypertension

Principles of treatment of secondary hypertension

  After detecting the cause of secondary hypertension and effectively removing or controlling the cause, the secondary hypertension can be cured or significantly alleviated. Based on different literature reports, secondary hypertension accounts for approximately 10% of the hypertensive population. The most common causes of secondary hypertension are renal hypertension (renal parenchymal disease, renal artery disease), endocrine Hypertension (primary aldosteronism, pheochromocytoma, hypercortisolism), obstructive sleep apnea syndrome, coarctation of the aorta, etc.
  The primary treatment principle of secondary hypertension is to provide targeted treatment of the cause of the identified primary disease. The application of antihypertensive drugs alone is not effective, and it cannot solve the problem fundamentally.
  Secondly, before the primary disease is cured, antihypertensive drugs should be used as early as possible under the guidance of professional physicians. The initial treatment usually adopts standard antihypertensive drug therapeutic dose, and gradually titrate to the tolerable dose as needed. It is recommended that the elderly start with a small dose. At the same time, long-acting preparations are preferred, and individualized treatment plans are formulated under the guidance of physicians.
  Thirdly, it is also possible to change bad living habits through non-drug means, thereby intervening the influence of different links in the pathogenesis of secondary hypertension on blood pressure, controlling risk factors and reducing target organ damage. Mainly include: ① low-salt diet, the daily sodium chloride intake of ordinary patients does not exceed 6 grams; ② weight control, try to maintain a healthy weight range [BMI 20-24, body mass index (BMI) = weight (kg) ÷Height (square meter)]; ③Exercise properly, exercise 5 times a week if you can tolerate it; ④Nutritious diet, pay attention to the combination of meat and vegetables, staple and non-staple food, reduce the intake of saturated fat and total fat; ⑤Quit smoking Quit drinking; ⑥Sleep enough and feel happy. If you have psychological fluctuations or mental illness, adjust your mentality in time, and if necessary, receive regular treatment in the psychology specialist.
General treatment plan for secondary hypertension

  1. Kidney substantial hypertension. Chronic glomerulitis, diabetic nephropathy, chronic pyelonephritis, and polycystic kidney disease are the main causes of renal substantive diseases that increase blood pressure. Under normal circumstances, renal substantive diseases can be diagnosed through renal function tests, imaging examinations, and routine urine examinations. If necessary, renal biopsy can be used to confirm the diagnosis. Such patients should go to the nephrology department for effective specialist treatment for the primary disease, and actively control the blood pressure to <130/80 mmHg. Angiotensin II receptor antagonist ARB and angiotensin converting enzyme inhibitor ACEI are the first choice antihypertensive drugs for patients with renal parenchymal hypertension with proteinuria. These drugs not only can effectively reduce the patient's blood pressure level, but also can effectively protect the patient's kidneys, which can successfully delay the patient's progression into end-stage renal disease, and are also very helpful for patients with moderate to severe renal insufficiency.   2. Renal arterial hypertension. The patient's blood pressure increased due to stenosis of one side of the patient's kidney or the main trunk of both renal arteries, or large branches of the renal arteries. Renal atherosclerosis, aortic arteritis and fibromuscular dysplasia are the most common causes of stenosis. Improving stenosis, controlling blood pressure, improving and protecting kidney function are the treatment principles of renal arterial hypertension. Specific treatment is generally based on surgery. For patients with stenosis ≥75%, percutaneous transluminal renal angioplasty (PTRA), renal artery stenting (metal stent) and other interventional therapies are the first choice. In severe cases, renal vascular reconstruction, nephrectomy, and autologous kidney transplantation can also be selected. Drug treatment is not the first choice for renovascular hypertension. Antihypertensive drugs are only used for those who are not suitable or who refuse to receive the above treatment. The first choice of drugs is calcium channel blockers, such as felodipine and nifedipine, which can effectively lower blood pressure and cause less renal damage. Unilateral renal artery stenosis can still be treated with ACEI or ARB. For bilateral renal artery stenosis, ACEI or ARB drugs are clearly prohibited.   3. Primary aldosteronism. High plasma aldosterone, hypokalemia, elevated blood pressure and low plasma renin activity are typical clinical manifestations of primary hyperaldosterone. Treatment includes surgery and medical medication. If it is diagnosed as unilateral adrenal hyperplasia or unilateral aldosteronoma, unilateral adrenalectomy is the first choice. If the patient has no indications for surgery (such as bilateral adrenal hyperplasia), does not have the willingness to operate, or cannot tolerate surgical treatment, medications should be taken. The first-line drugs are mineralocorticoid receptor antagonists represented by spironolactone and eplerenone, and spironolactone is often the first choice in China. If the therapeutic effect of such drugs does not reach the expected effect, long-acting calcium channel blockers, ARBs and other related drugs can be used in combination.   4. Pheochromocytoma. Surgery to remove the tumor is the most effective treatment. Most pheochromocytomas are benign tumors, and the patient’s blood pressure should be actively and effectively controlled before surgery to make adequate preparations for surgery. A-blockers can be taken to control blood pressure before surgery, and life-long follow-up should be followed after surgery. For patients with pheochromocytoma who cannot be operated due to subjective and objective factors, a-adrenergic receptor blockers and/or β-adrenergic receptor blockers can be used to control high blood pressure, tachycardia, and arrhythmia Wait for symptoms of discomfort.   5. Hypercortisolism. Hypercortisolism, also known as Cushing's syndrome, is a clinical syndrome caused by long-term excessive secretion of glucocorticoids in the adrenal cortex due to various reasons. The qualitative, localized diagnosis and treatment of hypercortisolism are more complicated, and may require close communication and collaboration with multi-specialists such as cardiology, endocrinology, general surgery and even neurosurgery. Hypercortisolism can be divided into two categories: non-ACTH-dependent Cushing's syndrome and ACTH-dependent Cushing's syndrome. ACTH-dependent Cushing syndrome mainly includes extra-pituitary tumors that secrete AClH (ectopic ACTH syndrome), ACTH cell proliferation, and pituitary ACTH tumors; non-ACTH-dependent Cushing syndrome mainly includes autosecreting cortex Alcohol adrenal adenoma, adenocarcinoma, or large nodular hyperplasia. Surgical treatment is mainly used for treatment. Commonly used operations include selective transsphenoidal or transcranial pituitary adenoma removal, and the postoperative remission rate is 65% to 90%. For those who do not remission or relapse after surgery, pituitary surgery or adrenalectomy can be performed again. Bilateral adrenalectomy or subtotal resection is an effective method for rapid control of hypercortisolemia, but there is a risk of Nelson syndrome after surgery. Radiotherapy for the pituitary gland as an adjuvant therapy has also been widely used in recent years. For medical treatment, ACEI or ARB is the first choice. If the blood pressure is not up to standard, it can be combined with alpha blockers or diuretics.   6. Obstructive sleep apnea syndrome. Obstructive sleep apnea hypopnea syndrome (OSAHS) is a type of sleep breathing disorder whose etiology is not fully understood. The patient’s pharynx muscle collapses during sleep and blocks the patency of the airway. The clinical manifestations include night sleep snoring with breathing Pause and daytime sleepiness. In recent years, as people’s awareness of the disease has become more and more common, the detection rate of obstructive sleep apnea syndrome is getting higher and higher, and the increase in blood pressure caused by obstructive sleep apnea syndrome is in secondary hypertension. The proportion of the population is on the rise. In terms of treatment, continuous nasal continuous positive airway pressure (CPAP) is the most effective treatment at present. Wearing an oral appliance during sleep can raise the soft palate, which is a better auxiliary treatment method. According to the comprehensive assessment of the location and severity of the airway obstruction, whether there is morbid obesity and the overall condition, various surgical methods such as tonsill and adenoidectomy, nasal cavity surgery, tongue plasty, palatopharyngoplasty, etc. can be used to improve symptoms when necessary . In addition, you can relieve snoring by improving your lifestyle and losing weight.   7. Other primary diseases. Secondary hypertension caused by coarctation of the aorta can be treated by surgical vascular surgery. Two methods, simple balloon dilatation angioplasty and stent implantation, are also used. Drugs can be used to control blood pressure under special circumstances, but the effect is generally not good. Patients with hyperthyroidism can choose anti-thyroid medication, radioactive iodine therapy, and surgical treatment according to their specific conditions. Patients with drug-induced hypertension should pay attention to asking whether they have taken drugs that raise blood pressure when asking about their medical history, and stop using them in time.