McAllister M D, Thompson W C, Pabian C J
Oakwood Hospital, Dearborn, Michigan.
Am Fam Physician. 1992 Oct;46(4):1225-30.
Because the cause of hypertension is reversible in only 5 percent of patients, extensive initial work-up should only be considered in selected cases. Secondary causes should be suspected in patients whose hypertension begins before age 30 or after age 50 and in patients whose hypertension suddenly worsens after a long period of good control, becomes severe or malignant, or remains refractory to maximal medical therapy. A sudden reduction in renal function in a hypertensive patient and the discovery of a unilateral small kidney may also raise suspicion of a secondary cause. Renovascular disease, one of the most common secondary causes of hypertension, is usually the result of atherosclerosis in older patients and the result of fibromuscular dysplasia in younger patients. Physical examination seldom contributes to the diagnosis. The classic upper abdominal or flank bruit occurs in only 30 to 50 percent of patients with renovascular disease, and is not uncommon in patients with essential hypertension. The gold standard for diagnosis of renovascular disease remains the arteriogram. Transluminal renal angioplasty may be performed during arteriography if a high-grade stenosis is identified. Other management options include medical therapy and surgical revascularization with grafts.
由于仅5%的高血压患者病因是可逆的，因此广泛的初始检查仅应在特定病例中考虑。对于高血压发病于30岁之前或50岁之后的患者，以及长期血压良好控制后突然恶化、变得严重或呈恶性、或对最大程度的药物治疗仍难治的高血压患者，应怀疑继发性病因。高血压患者肾功能突然减退以及发现单侧小肾也可能提示继发性病因。肾血管疾病是高血压最常见的继发性病因之一，在老年患者中通常是动脉粥样硬化的结果，而在年轻患者中是纤维肌发育异常的结果。体格检查对诊断的帮助不大。经典的上腹部或侧腹杂音仅出现在30%至50%的肾血管疾病患者中，在原发性高血压患者中也不少见。肾血管疾病诊断的金标准仍然是血管造影。如果发现高度狭窄，可在血管造影期间进行经腔肾血管成形术。其他治疗选择包括药物治疗和使用移植物进行外科血管重建。
