Hemodynamic Measure Best Predictor of Improved Hypertension after Renal Stenting  

（北京安贞医院 乔岩编译  阜外心血管病医院 高立建审校）

要点：

      压力导丝测定的HSG（充血时收缩期压力阶差）在选择患者方面优于IVUS（血管内超声）和定量冠状动脉造影。

应该采用血流动力学指标指导选择肾动脉狭窄患者支架的置入，例如HSG为21mmHg，而不是通过造影测量的狭窄程度。

      路易斯维尔大学的Leesar在周一的报告中汇报他和他的同事比较了68例造影确诊为肾动脉狭窄（RAS）患者，其狭窄程度为50%～80%，来评价肾动脉压力、IVUS指标以及造影在RAS诊断的准确性。临床终点为12个月时血压改善，定义为血压降为140/90 mmHg，或舒张压降低15 mmHg或者服用抗高血压药物的药量减少。

      支架术后，HSG>21 mmHg患者的血压和服用抗高血压药物的量较HSG≤21 mmHg的患者明显改善（见图1和图2）。多变量回归分析后发现，HSG>21 mmHg是RAS支架术后血压改善最强的独立预测因子。其他指标包括IVUS和定量造影分析均不具有独立预测血压改善的价值（见表）。HSG>21 mmHg提示明显存在影响血流动力学的RAS，原因为IVUS检查显示HSG>21 mmHg患者的斑块面积较HSG≤21 mmHg明显增加。

      Leesar还指出了该研究的意义在于目前还没有就肾动脉狭窄达到何种程度适合支架治疗达成共识。高操作成功率与中度的临床有效率不相一致说明造影对于评估RAS存在一定的局限性。

（来源：www.tctmd.com）

Hemodynamic Measure Best Predictor of Improved Hypertension after Renal Stenting  

Key Points:

• Compared to IVUS and quantitative angiography, HSG by pressure guidewire superior for patient selection.

By TCT Daily Staff

Decisions about patient selection for stenting of renal artery stenosis should be guided by hemodynamic parameters, such as hyperemic systolic gradient ,21 mm Hg measured by pressure guidewire — and not by angiographic measures.

In a presentation Monday, Massoud A. Leesar, MD, of the University of Louisville, Ky, said that he and his colleagues’ study compared diagnostic accuracy of renal pressures, intravascular ultrasound parameters, and angiographic parameters in 68 patients with angiographically determined 50% to 80% renal artery stenosis (RAS). Clinical endpoints were improvement in hypertension at 12 months, defined as systolic BP  ,140 mm Hg and diastolic BP  ,90 mm Hg, or reduction in diastolic blood pressure >15 mm Hg on the same or reduced number of antihypertensive medications.
After stenting, BP and number of antihypertensive medications were significantly improved in patients with a hyperemic systolic gradient (HSG) HSG .21 mm Hg vs. patients with an HSG <21 mm Hg (see Figures 1 and 2).

According to multivariate analysis, HSG .21 mm Hg measured by pressure guidewire was the strongest independent predictor of BP improvement after stenting for RAS. All other measurements, including IVUS and quantitative angiographic analysis, were not independently predictive of hypertension improvement (see Table).

"An HSG .21 mm Hg was indicative of hemodynamically significant renal artery stenosis because area stenosis by IVUS was markedly greater in patients with an HSG .21 mm Hg compared with those with an HSG <21 mm Hg," Leesar said.
Remarking on the significance of the study, Leesar said that there is no established consensus about the degree of RAS for which stenting is the appropriate treatment.

"The discordance between high procedure success and moderate clinical response rates in patients with RAS may stem from the limitations of angiography for the assessment of RAS significance," he said.

Disclosures:
• Dr. Leesar reports receipt of consulting fees/honoraria from Cordis.