Prognostičko značenje serumske razine BNP na uspjeh endovaskularne intervencije u renovaskularnoj hipertenziji

Fodor, Ljiljana (2015) Prognostičko značenje serumske razine BNP na uspjeh endovaskularne intervencije u renovaskularnoj hipertenziji. PhD thesis, Sveučilište u Zagrebu.

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Abstract

Optimal therapeutic approach in renovascular hypertension (RVH) is still controversial. Beside debate on whom and when intervention might be beneficial, this study analyzed whether elevated BNP levels before the intervention can be a predictor of a successful outcome on blood pressure and renal function. In everyday clinical practice physicians are still reluctant in prescribing drugs that inhibit renin-angiotensin system after the procedure. This study also analysed safety and possible positive effects of sartans in patients with RVH after procedure. Arterial stiffness is an independent cardiovascular risk factor. Aging, high blood pressure and increased renin-angiotensin system activity contribute to increased arterial stiffness in patients with RVH. A literature search failed to identify any study related to this topic. Therefore, aim of this study was to determine the arterial stiffness in patients with RVH and analyzing whether stenting in addition to multifactorial drug therapy has beneficial effects on markers of stiffness and the clinical course. Thirty seven patients with RVH were enrolled. The inclusion criteria were: serum creatinine <250 µmol/L, renal artery atherosclerotic stenosis ≥ 50%, and exclusion criteria was intolerance to ACEi or ARBs, hyperkalemia (K >5 mmol/L), pregnancy and nephrotic proteinuria. Office and ambulatory blood pressure (BP), augmentation index (AIx), pulse wave velocity (PWV), central mean BP (MAP) , eGFR and serum potassium were determined before stenting, 48 hours 6 and 36 months after the intervention. Telmisartan 80 mg (on top) was induced in all patients after stent placement. Significant decrease in NT-proBNP( > 30%) had most of the patients 48 hours after stenting. Significant decrease in BP and improvement in kidney function were observed in this cohort of RAH subjects six months after stenting already. Significant decrease in AIx could be explained with improved renal function but also might be due to the treatment with sartans. PWV is not decreased 6 months after stenting, but decreased significantly after 36 months. Results of this study indicate that intervention in RAH, at least six months after the intervention has beneficial effect on BP and kidney function. Treatment with sartans after stenting in patients with RVH is safe and might contribute to overall positive effect. In conclusion, this study is the first to show that arterial stiffness is higher in patients with refractory RVH than in those with essential hypertension. NT-proBNP and markers of arterial stiffness determined before revascularization were not predictors of either BP or kidney function outcome.

Abstract in Croatian

Optimalan terapijski pristup u RVH još je uvijek sporan. U ovoj studiji provedena je analiza kojim bolesnicima i kada endovaskularna intervencija s implantacijom stenta uz medkamentnu terapiju može biti korisna, te da li povišena razina BNP prije zahvata može biti prediktor uspješnog ishoda na arterijski tlak i bubrežnu funkciju. U svakodnevnoj kliničkoj praksi liječnici još uvijek imaju otpor propisivanju lijekova koji inhibiraju RAAS, čak i nakon zahvata. Stoga je analizirana sigurnost i mogući pozitivni učinci sartana u bolesnika s RVH nakon stentiranja. Krutost arterija je neovisan čimbenik kardiovaskularnog rizika. Starija dob, povišen arterijski tlak i povećana aktivnost RAAS povećavaju krutost arterija u bolesnika s RVH. U literaturi nema dosadašnjih istraživanja u vezi s ovom temom. Cilj je ove studije odrediti krutost arterija u bolesnika s RVH, te analizirati ima li stentiranje udruženo s polimorfnom medikamentnom terapijom povoljan učinak na markere krutosti. Uključeno je 37 bolesnika s RVH. Uključni kriteriji su : kreatinin u serumu <250 umol / L, arterosklerotsko stenoza RA ≥ 50%, duljina bubrega ≥ 80mm, a isključni kriteriji : netolerancija na ACE inhibitore ili blokatore angiotenzinskih receptora, hiperkalijemija (K> 5 mmol / L), trudnoća i nefrotska proteinurija. Ambulantno mjerenje AT, augmentacijskog indeksa (AIx), pulsnog vala ( PWV), centralng AT i GFR određivani su prije, 48 sati nakon stentiranja, te u periodu praćenja od 6-36 mjeseci. Bolesnicima je nakon stentiranja u terapiju uključen telmisartan (80mg). Do značajnog smanjenja razine NT-proBNP( > 30%) dolazi u većine bolesnika 48 sati nakon stentiranja. Značajan pad AT i poboljšanje bubrežne funkcije zabilježen je u ovoj skupini bolesnika nakon 6 - mjesečnog praćenja. Značajno smanjenje Aix može se objasniti poboljšanom bubrežnom funkcijom, ali također biti posljedica liječenja sartanima. PWV se nije smanjio u prvih 6 mjeseci nakon stentiranja, ali bilježi se značajno smanjenje nakon 36 mjeseci. Rezultati ove studije pokazuju da stentiranje u RVH uz medikamentnu terapiju ima povoljan učinak na AT i bubrežnu funkciju već 6 mjeseci nakon postupka. Terapija srtanima u ovih je bolesnika sigurna i može doprinijeti ukupnom povoljnom učinku. Zaključno, ovo je prva studija koja je pokazala da je arterijska krutost veća u bolesnika s RVH nego u bolesnika s EH.NT-proBNP i markeri arterijske krutosti određeni prije stentiranja, nisu prediktor ishoda u odnosu na arterijski tlak i bubrežnu funkciju, niti nakon ukupnog perioda praćenja.

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