Hypertension Annual Meeting 2020 . Zhang Huimin: Secondary hypertension - a major arteritis that cannot be ignored.

The trend of young hypertension has become more and more obvious, aorticitis is one of the important causes of hypertension in young people and even children, but it is often ignored by clinicians, in the clinic due to misdiagnosis or missed diagnosis of young patients eventually appear heart failure (referred to as heart failure) or even death is not uncommon.
it urgent to raise clinicians' awareness of aorticitis.
September 17, 2020, at the 2020 China Annual Conference on Hypertension and the 22nd International Symposium on Hypertension and Related Diseases, Professor Zhang Huimin of the National Cardiovascular Center and Hypertension Center of the Chinese Academy of Medical Sciences, combined with clinical experience, shared a wonderful discussion on the clinical manifestations of aortic inflammation, the causes of induced hypertension and its diagnosis and treatment.
clinical manifestations of hyperarthritis in China, the incidence ratio of young men and women with arteritis is 1:3.8, with women in the majority.
Aorticitis is a chronic, progressive, full-layer nonse specific arteritis, which can lead to the thickening of the affected artery walls, narrow, closed or dilation of the arterial tube cavity, can be accompanied by thrombosis, occasional tumor-like changes.
pathogenesis is not clear, more is thought to be related to infection, immune disorders and inflammatory cellular response.
many patients with aorticitis in hospitals outside the hospital have developed into advanced stages, the main reason is that the early symptoms of arteritis are very recessive, coupled with hospitals at all levels are not familiar with the disease leading to patients missing.
Early symptoms may be only fatigue, joint pain, muscle pain, individual fever, but the incidence of this is less than 10%;
, it is important to identify and diagnose aorticitis at an early age. figure
(Figure 1) Figure 1. High blood pressure, which cannot be ignored in patients with aorticitis clinical manifestations, is found in the data of 566 cases of aorticitis in hospitals outside the hospital, and atheritis combined hypertension accounts for the majority (330/566 cases, 58.3%), followed by dizziness caused by progressive cervical arteries, with acute patients suffering from early symptoms of only 10%, indicating that most patients are in other hospitals after missed diagnosis and misdiagnosis.
, children with aorticitis have a similar phenomenon.
, aortic inflammation can cause high blood pressure in different areas.
, aortic inflammation can affect the renal arteries, causing renal hypertension, which is the most likely cause of hypertension.
Atherosclerosis is the most important cause of renal vascular hypertension, fibromyalgia development (FMD) can also cause renal vascular hypertension, and aorticitis and FMD are common in young people, usually different imaging, but some internal models and external models FMD imaging characteristics similar to aortic inflammation, characterized by long-term diffuse or narrow limitations.
Taking into account that the treatment plan of aorticitis and FMD is completely different, FMD can be directly expanded as long as the diagnosis is clear, but for aorticitis needs to assess its activity, and systematic anti-inflammatory treatment, patients can start and end well, otherwise it is easy to appear again narrow and other problems.
, it is important to identify aorticitis and FMD.
, aortic inflammation can affect the aorta, leading to aortic stenosis and high blood pressure.
aortic stenosis, the mechanical resistance of the aorta increases, which can cause blood pressure in the upper extremities to be higher than that in the lower extremities.
same time, because the blood flow of the kidney arteries is blocked, resulting in increased RAS activity, causing high blood pressure.
patients with more recessive morbidity, only high blood pressure, can be eliminated through CT examination aortic stenosis.
However, aortic stenosis should be noted to be identified with congenital aortic narrowing, which has developed congenital malformations of the aorta since embryonic stage, and usually shows high blood pressure very little or very late, and late appearance of heart insanity.
, care should be paid to distinguish between aortic inflammation and congenital aortic narrowing.
Clinically, a number of children admitted to hospital with heart failure were admitted to hospital outside the hospital, their early manifestations were intermittent lameness, walking leg pain, but easy to be diagnosed with calcium deficiency, and then high blood pressure caused by dizziness, but clinicians usually do not measure children's blood pressure caused by their missed diagnosis, and then appeared walking panic short, developed into heart failure.
refore, blood pressure monitoring should be strengthened in young people, for patients with hypertension with vascular murmurs should not be ignored, CTA examination should be carried out in a timely manner to rule out whether it is due to aortic inflammation and aorta-induced hypertension.
Other hypertensions caused or associated by aorticitis include: aortic inflammation and ascending aorta, causing ascending aortic dilation or aneurysm, causing secondary aortic valve closure incomplete, leading to contractionary hypertension; Cause aortic valve closure incomplete, give glucosinosteroid therapy of aortic inflammation patients can cause or aggravate hypertension due to water sodium retention, in addition, the continuous inflammatory stimulation of aortic inflammation, can cause the aortic mezzanine, clinically manifested as the progression of hypertension, aggravation.
major arteritis diagnosis and treatment of clinical diagnosis, in 1990 the United States Rheumatology Association (ACR) standards are still used, and now the clinical age limit is no 1st important standard, but if there is isteemia, double pulse asymmetry, blood pressure asymmetry, vascular murmurs, image prompt ring thickening, as long as 3 can be diagnosed as major arteritis.
However, some patients are not fully diagnosed according to the ACR standard, which includes 2 main standards and 10 secondary criteria according to the 1996 Modification Ishikawa diagnostic standard, which allows patients to be diagnosed as long as they meet 1 major standard, plus 2 secondary criteria, or 2 primary criteria, or 4 secondary criteria.
standard basically covers the diagnostic characteristics of all major arteritis (Figure 2).
, Hata and Numano can be used to class 5 major arteritis, compared to the Chinese Medical Association is more simplified into two types.
2. If the diagnosis of aorticitis is not difficult, its active evaluation is relatively difficult.
clinical systemic symptoms are rare, and increased blood flow is common, but not specific.
the most important should be based on systemic symptoms, blood sinking, affected blood vessel isoemia and inflammation, gloom can be seen new typical vascular damage, in line with 2 or more patients can be diagnosed as active aortic inflammation.
(Figure 3) Figure 3. At the same time, the diagnosis of hyperarthritis activity, aorticitis has special clinical imaging characteristics.
imaging testing methods include angiogram, CTA, 18F-FDG-PET, MRA, and vascular ultrasound.
The most widely used in China is CTA, the use of CTA can obtain some special imaging information, including ring thickening, endometrial edema, combined with 18F-FDG-PET imaging, you can see the inflammation of vasody, diagnostic sensitivity, specificity is higher.
addition, clinical laboratory tests, including blood sink, C-reactive protein, blood image, have some help in diagnosis.
(Figure 4) Figure 4. In the diagnosis and treatment of aorticitis, chronic patients can be observed and followed up, and blood transport reconstruction may not be considered unless blood vessel obstruction is life-threatening or vital organ function is impaired. Patients during the
active period should be treated with anti-inflammatory treatment, although clinically stable, but also anti-inflammatory for more than 2 months;
(Figure 4) In the treatment of anti-hypertension, the choice of anti-hypertensive drugs should take into account the blood vessel-affected areas, tired and two-sided renal arteries are not suitable for the use of RAS-like antagonists;
in the reconstruction of blood transport, aorticitis and arteriosclerosis and FMD is not the same, not because of vascular stenosis must be placed in the stent, otherwise it may lead to repeated blood vessels again narrow.
Clinically should be early screening, full anti-inflammatory, such as anti-inflammatory after the presence of vascular stenosis (such as renal artery stenosis, aortic stenosis, etc.) affect the patient's blood pressure, tired and other important blood vessels, only consider to the patient for revascularization, but then vascularization can only be balloon dilation, not stent, unless the aorta is prone to mezzanine may be self-puffing stent, other parts are generally using vascular dilation.
(Figure 4) has found that surgical treatment can be very effective in some patients who are unable to intervene, and the rate of re-narrowing is lower.
In short, patients with arteritis after systematic treatment, blood pressure can be effectively controlled, prognosis is mainly affected by the degree of hypertension, affected blood vessels, whether early diagnosis and early treatment (this is very important!). ), the length of the disease and the condition of the side branch circulation, etc.
(Figure 4) total arteritis is chronic carrying vascular lesions.
hypertension is often the primary cause of treatment in patients with aorticitis, early diagnosis and treatment can improve prognosis.
hypertension caused by hyperarthritis is associated with renal artery, aorta, aortic valve injury and hormone application, and attention should be made to identify atherosclerosis, FMD, congenital aortic narrowing.
hormone therapy course should be long, reduce the amount is slow, and then angiotherapic treatment can improve isoemia, lower blood pressure, but the long-term has a certain rate of re-narrowing, should be long-term follow-up, dynamic observation of arterial injury.
mainly depends on the degree of hypertension and the prevalence of important organs.
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