BENH TANG HUYET AP :

C CHE, DCH TE, LAM SANG VA CHAN OAN

PGS. TS. PHAM NGUYEN VINH
BS. HA NGOC BAN
1. Nguyen nhan va benh sinh cua benh tang huyet ap (THA)
1.1 Yeu to di truyen trong THA
1.2 Cac yeu to benh sinh khac cua THA
2. nh ngha, phan loai va dch te hoc cua THA
3. Lam sang cua benh THA
3.1 Trieu chng c nang
3.2 Benh s
3.3 Kham thc the
3.4 Xet nghiem lam sang
4. Bien chng tim, than va nao cua benh THA
4.1 Bien chng tim cua THA
4.2 Bien chng than cua THA
4.3 Bien chng nao cua THA : ot qu
5. Chan oan nguyen nhan THA (THA th phat)
5.1 THA do benh mach mau than
5.2 THA do benh nhu mo than
5.3 THA do benh tuyen thng than

1. NGUYEN NHAN VA BENH SINH CUA BENH THA

Hai yeu to tao thanh HA la cung lng tim va sc can mach ngoai
vi :
HA = cung lng tim x sc can mach ngoai vi
Cung lng tim tao thanh bi cac yeu to : sc co c tim, tan so,
nhp tim, tien tai, he than kinh t chu va s toan ven cua cac
van tim. Sc can mach ngoai vi (SCMNV) tao thanh bi am o cua
mau, o dai cua mang ong mach va o hep cua ng knh
long mach. Hai yeu to au cua SCMNV thng khong thay oi, do
o SCMNV tuy thuoc phan ln vao ng knh cac ong mach
nho (< 1mm). o cng cac ong mach ln cung anh hng en
HA tam thu.
THA thng c chia ra THA tien phat (khoang 90% trng hp,
khong biet nguyen nhan) va THA th phat (biet nguyen nhan).
Cac yeu to sinh ly benh lien quan en THA tien phat bao gom :
gia tang hoat tnh giao cam co the do stress tam ly xa hoi, tang
san xuat hormone gi muoi va co mach nh endotheline va
thromboxane, an man lau ngay, an khong u kali va calci, tiet
renin khong phu hp, thieu cac chat dan mach nh prostaglandins
va nitric oxide (NO), bat thng mach khang (resistant vessels) bam
sinh, beo ph, tang hoat yeu to tang trng va thay oi van
chuyen ion qua mang te bao.
1.1

Yeu to di truyen trong THA

Chng c ve di truyen la nguyen nhan cua THA bao gom :

- Tng quan ve THA gia sinh oi ong hp t (monozygotic twins)
so vi sinh oi d hp t (dizygotic twins)
-

Tng quan ve THA trong 1 gia nh. Hien nay mi xac nh c

bien chng cua khoang 10 genes gay ra THA (1). Cac bien
chng nay anh hng en HA qua trung gian gi muoi va nc
than. Khong ch la yeu to gene, co the co tng tac gia
cac yeu to moi trng, dan so va gene trong THA.

Nghien cu c thc hien nhieu nhat ve di truyen THA la hoi

chng Liddle, lien quan en bien chung beta va gamma subunits
cua ASSC (amiloride sensitive sodium channel). Hoi chng Liddle la
benh di truyen nhiem sac the thng va troi, co ac iem la
THA do tang the tch kem renin thap, aldosterone thap. Benh khu tru
trong than v ghep than se het benh. THA do hoi chng Liddle
thng khang tr (resistant hypertension) nhng ap ng vi thuoc
triamterene hoac amiloride.
Can phai tm hoi chng Liddle khi THA khang tr v mot nghien cu
cho thay 25% THA khang tr do hoat hoa ASSC (2).
2

1.2

Cac yeu to benh sinh khac cua THA

1.2.1 Tang hoat giao cam

Tang hoat giao cam dan en THA qua s kch hoat tim (tang cung
lng tim), than (gi nc) va mach ngoai vi (co mach). Nghien cu
CARDIA theo doi 4762 benh nhan t 18-30 tuoi trong 10 nam cho
thay tan so tim la yeu to tien oan oc lap benh THA (3). Yeu
to chnh cua tan so tim nhanh la tang hoat giao cam.
S dung dung cu o vi than kinh (microneurography) nham xac nh
hoat tnh giao cam than kinh ngoai vi va c cho thay hoat tnh
giao cam tang ngi THA so vi ngi HA bnh thng (4).
1.2.2 Tang hoat mach mau va tai cau truc mach mau
Ngi co tien s gia nh THA, se tang co mach khi gap lanh hay
stress tnh cam, do o de b THA (5).
Tai cau truc mach mau lam tang sc can mach ngoai vi do o
lam THA. Sinh thiet mo c benh nhan THA tien phat khong ieu
tr cho thay lp trung mac b day va giam khau knh long mach
(6).
1.2.3 o cng ong mach
HA tam thu va ap lc mach (pulse pressure- o chenh gia HA tam
thu va HA tam trng) gia tang khi o cng ong mach ln gia
tang. o cng mach mau ln tang do x cng ong mach va voi
hoa.
Van toc song mach (pulse wave velocity) ngi tre khoang
5m/giay, do o song phan hoi ve ti van MC vao luc van a
ong. Nh o ap lc mau tam trng cao, giup ti mau u cho
mach vanh.
ngi cao tuoi ong mach cng hn, o dan (compliance) giam,
van toc song mach co the len ti 20m/giay. Do o song phan
hoi tr ve vao luc van MC m. Hau qua la ap lc tam thu cao,
ap lc tam trng giam va ap lc mach gia tang (hnh 1) (7).

Hnh 1 : o dan mach va van toc song mach

TL : O'Rourke MF et al. Left ventricular systemic arterial coupling in humans and strategies
to improve coupling in disease states. In : Yin FCP, ed : Vascular/Ventricular coupling. New
York ; Springer. Verlag 1987 : 1-19

1.2.4 He thong renin va angiotensin

He thong renin-angiotensin-aldosterone ong vai tro quan trong trong
ieu hoa HA ca ngi bnh thng lan ngi b benh THA. Renin
c tong hp va phong thch t cau truc canh vi cau than, co
vai tro xuc tac chuyen angiotensinogen thanh angiotensin I (AG I). Qua
trung gian cua men chuyen (ACE), AG I c chuyen thanh angiotensin
II (AG II). AG II co tac dung trc tiep co mach can, kch thch tong hp
va phong thch aldosterone, kch thch tai hap thu natri t ong than
(trc tiep hay qua trung gian aldosterone), c che phong thch renin,
kch thch tiet ADH (antidiuretic hormone) va tang hoat giao cam (hnh
2).

Hnh 2 : S tao lap angiotensin va tac ong cua chat nay

len c quan

TL : Goodfrend et al. Angiotensin receptors and their antagonists. N. Engl J Med 1996 ; 334 :
1649-1654

Angiotensin II con co tac ong tang trng va tang sinh te bao,

thuc ay te bao va tang sinh va ph ai. AG II tac ong c
qua trung gian thu the. a xac nh c 2 thu the chnh AT1 va
AT2. Thu the AT 1 khi c kch hoat bi AG II se cho cac tac dung
neu tren. Ngc lai thu the AT 2 khi c AG II kch hoat se lam
gian mach, chong tang trng va co the chong thieu mau cuc
bo. S tao lap AG II khu tru cac c quan co the qua ng khac
vi ng ACE. tim va mach mau, AG II con tao lap c qua
ng chymase. Hoat ong cua he renin-angiotensin khu tru (tai
mo) co the ong vai tro quan trong trong benh tim mach.
Renin c tang tiet khi ti mau than giam. THA tien phat co
the co renin mau thap hoac renin mau cao. Tuy nhien thuoc UCMC
va thuoc chen thu the AT 1 cua AG II co hieu qua ha HA tren ca
benh nhan THA co renin mau thap lan benh nhan co renin mau
cao.
1.2.5 Aldosterone
Cng aldosterone tien phat co the do bu tuyen thng than
(adrenal adenoma- hoi chng Conn) hoac tang sinh thng than
5

(adrenal hyperplasia). Trc kia benh nay ch chiem < 1% nguyen

nhan THA. Nghien cu gan ay, da vao o ty le hoat tnh
aldosterone huyet tng/renin huyet tng cho thay cng aldosterone
co the len en 8-12% benh nhan THA (8). Rieng vi THA khang
tr, nguyen nhan cng aldosterone co the la 17% (9). Nh vay, co
the co mot yeu to nao khac, cha biet ro lam tang tiet
aldosterone.
1.2.6 Muoi Natri
Co nhieu chng c ve vai tro cua muoi Natri trong THA (10).
- nhieu quan the dan chung, s tang HA theo tuoi co tng
quan trc tiep vi lng natri tieu thu.
-

nhieu nhom dan chung rai rac, khi tieu thu t muoi natri se
khong co hay rat t THA. Khi tieu thu nhieu natri, THA xuat hien.

THA xay ra ong vat khi cho an nhieu muoi natri, neu cac
ong vat nay co yeu to di truyen THA.

vai ngi, an nhieu muoi natri mot thi gian ngan, sc can
mach tang va HA tang

Nong o muoi natri cao hien dien mach mau va te bao

mau ngi THA

Han che muoi natri < 100 mmol/ngay se giam HA hau het
benh nhan. Tac dung ha ap cua thuoc li tieu can khi au
bang tieu ra natri.

D muoi natri ch dan en THA khi than khong ao thai c Co

nhieu yeu to dan en than khong ao thai c natri : giam so
nephron bam sinh, mat tng quan gia ap huyet va s bai tiet
natri than, s khong tng ong gia cac nephron, c che bm
natri mac phai, thieu ap ng vi hormone bai natri t nh (ANP :
atrial natriuretic hormone).
1.2.7 Nitric oxide (NO) va Endothelin
NO c coi la co vai tro quan trong trong ieu hoa HA, tao huyet
khoi va x va ong mach. NO la chat tiet ra bi te bao noi
mac, ap ng vi kch thch nh thay oi HA, sc cang thanh mach.
NO co thi gian ban huy rat ngan, co cac ac tnh sau : tac dung
dan mach manh, c che s ket tap tieu cau, ngan can s di
chuyen va tang sinh te bao c trn.
Endothelin la chat co mach manh, tiet ra bi te bao noi mac. Tren
mot so benh nhan THA co s gia tang endothelin trong mau.
Endothelin co the co vai tro trong THA tien phat. Tuy nhien thuoc
oi khang endothelin cha c s dung trong ieu tr THA do oc
tnh ; mot so thuoc oi khang endothelin ang s dung trong ieu
tr tang ap ong mach phoi.
6

2 NH NGHA, PHAN LOAI VA DCH TE HOC BENH THA

HA c qui nh bi cung lng tim va sc can mach ngoai vi. Tr
so HA goi la bnh thng co tnh cach tng oi. Nhieu ngi HA
t lau la 90/60mmHg van lam viec bnh thng va khong co
trieu chng. So lieu e phan biet HA bnh thng, bnh thng cao
hay tien THA eu da tren cac thong ke cac quan the ln dan
chung khong co bien chng cua THA.
Trc kia THA thng c phan o da tren tr so HA tam trng.
Hien nay phan o THA da tren ca HA tam thu lan HA tam trng.
THA tam thu n thuan xay ra khi HA tam thu >140mmHg con HA
tam trng < 90mmHg. THA tam thu n thuan thng xay ra
ngi cao tuoi.
Da vao phuc trnh so 7 cua uy ban lien hp quoc gia nham phat
hien, lng gia, phong nga va ieu tr THA (JNC 7) (11) ; phan o
THA ch con 2 o va giai oan tien THA (bang 1).
Bang 1 : Phan o THA ngi ln > 18 tuoi

Phan o THA
HA tth,
bat buoc Co ch nh
mmHg
mmHg
buoc
Bnh thng < 120
va < 80
Tien THA
120 80 ch
139
hoac 89
THA g1
ch
bat buoc

140 159

X tr
Khi au ieu tr
HA ttr,
Thay oi Khong ch nh
loi song

bat

Khuyen khch
Can Khong ieu tr thuoc

90 Can
hoac 99

Thuoc

cho

nh bat buoc
Li tieu cho hau het trng
Thuoc
cho
hp; co the UCMC, chen
nh
thu the AGII, chen beta; UC
calci hoac phoi hp

THA g2
>160 hoac > 100 Can
Thuoc cho ch

Phoi hp 2 thuoc/ hau het

trng hp

nh bat buoc

Phan o cua Hoi tim mach va Hoi THA Chau Au co hi khac (12).
Phan o nay van gi phan o cua JNC 6 (1997) va phan o cua
To chc Y te the gii (1999).
Bang 2 : nh ngha va phan o HA (mmHg) cua Hoi Tim
mach va Hoi THA Chau Au
Mc o
Ly tng
Bnh thng

HAtth
< 120
120-129

HAttr
< 80
80-84

Bnh thng cao

130-139
THA o 1 (nhe)
140-159
THA o 2 (va)
160-179
THA o 3 (nang)
> 180
THA tam thu n thuan
> 140
TL : Journal of Hypertension 2003 ; 21 : 1011-1053

85-89
90-99
100-109
> 110
< 90

Tuan suat (prevalence) THA thay oi theo tuoi, gii tnh, chung toc
va a d. Tai Hoa Ky, tan suat chung ve THA ngi ln khoang
24% (13). Tai Viet Nam, nghien cu tai mien Bac cho thay tan suat
THA khoang 16% (14). Tai mot so vung tren the gii tan suat THA
rat thap (hnh 3).

Hnh 3 : Mot vai quan the co HA thap tai vung a d tren

the gii

TL : Pulter and Sever. Blood pressure in other populations. In Swales JD (ed). Textbook of
hypertension. Oxford : Blackwell Scientific Publishers 1994 ; p. 22-36

Bang 3 : Tan suat THA ngi ln tai Hoa Ky theo chung

toc va gii tnh

TL : Burt et al. Hypertension 1995 ; 25 ; 305-313

Hnh 4 : Tan suat THA theo tuoi va chung toc

TL : Burt et al. Hypertension 1995 ; 25 : 305-313

3 LAM SANG BENH THA

3.1 Trieu chng c nang
Phan ln benh nhan THA khong co trieu chng c nang, phat
hien benh co the do o HA thng quy hoac khi a co bien chng
(TD = TBMMN).
Trieu chng cua ngi benh khi co, co the nam 1 trong 3 nhom :
- Do HA cao
- Do benh mach mau cua THA
- Do benh can gay ra THA (THA th phat)
Cac trieu chng do chnh mc HA cao co the la : nhc au, xay
xam, hoi hop, de met va bat lc. Nhc au thng ch xay ra
khi co THA nang. Thng nhc au vung cham, sau gay va
thng vao buoi sang.
Cac trieu chng do benh mach mau cua THA la : chay mau mui,
tieu ra mau, m mat, cn yeu hay chong mat do thieu mau nao
thoang qua, cn au that ngc, kho th do suy tim. oi khi co au do
boc tach MC hoac do tui phnh MC r xuat huyet.
Cac trieu chng do benh can gay ra THA bao gom : uong nhieu,
tieu nhieu, yeu c do ha kali mau benh nhan cng Aldosterone
tien phat hoac tang can, de xuc ong benh nhan b hoi
chng Cushing. benh nhan b u tuy thng than thng b nhc
au, hoi hop, toat mo hoi, xay xam t the.
3.2

Benh s

Tien s gia nh b THA kem theo THA tng luc trong thi gian trc
giup ngh en benh THA tien phat.
THA th phat can ngh en ngi benh THA di 35 tuoi hoac
tren 55 tuoi ma THA nang va nhanh.
Tien s s dung kch thch to thng than hoac oestrogene
10

Tien s nhiem trung tieu nhieu lan giup ngh en viem ai be

than man.
Tien s tieu em va uong nhieu giup ngh en nguyen nhan
than hay noi tiet. Chan thng vung hong giup ngh en ton
thng than.
Tang can giup ngh en hoi chng Cushing, trong khi giam can
giup ngh en u tuy thng than hay benh Basedow.
Cac yeu to nguy c khac cua x va ong mach can c xem
xet : hut thuocla, tieu ng, roi loan lipid mau.
Ngoai ra can hoi ve cach song ngi benh, nghe nghiep, cach
an uong, hoat ong the lc
3.3

Kham thc the

Quan sat chung : mat tron kem map than hn la chi giup ngh
en hoi chng Cushing. Phat hien bap tht chi tren phat trien hn
chi di giup ngh en hep eo MC.
So sanh HA va mach 2 chi tren va 2 chi di. o HA t the
nam va ng (t nhat 2 phut). HA tam trng gia tang khi oi t
nam ra ng giup ngh en THA tien phat, neu giam giup ngh
en THA th phat (vi ieu kien benh nhan cha uong thuoc ha
ap).
Soi ay mat giup lng gia thi gian THA va tien lng.
S va nghe ong mach canh xem co hep khong. ay co the la
bieu hien cua benh mach mau do THA hoac co ton thng ong
mach than. Kham tim va phoi giup phat hien co tim ln, co
tieng T3, T4 va co ran ay phoi. Can tm tieng thoi ngoai tim do
tuan hoan bang he cua hep eo MC.
Kham bung bao gom :
- Nghe bung, vung tren ron ben phai va trai ng gia,
vung 2 ben hong giup tm am thoi cua hep M than.
-

S bung e tm tui phnh MC bung hoac than ln do benh than

a nang.

Can s mach ben, neu yeu va/hoac cham so vi mach co tay,

can o HA ha chi.
Kham chi di xem co phu hoac di chng cua TBMMN.
3.4

Xet nghiem can lam sang

11

Cac xet nghiem c ban can thc hien cho tat ca benh nhan
THA :
- Huyet o, dung tch hong cau
- Uree mau, creatinine mau
- Tong phan tch nc tieu (ng, am, hong cau, can lang)
- ng mau, cholesterol mau, Triglyceride mau, HDL, LDL
- Acid urique mau
- Phim long ngc
- ien tam o
- Sieu am tim
Cac xet nghiem nham tm nguyen nhan THA :
- Benh mach mau than : sieu am ong mach than, chup cat lp
ien toan hoac anh cong hng t, chup mach than
- U tuy thng than : nh lng Catecholamine hoac Metanephrine
nieu trong 24 gi
- Hoi chng Cushing : trac nghiem c che dexamethasone hoac
nh lng Cortisol nieu trong 24 gi
Bang 4 : Phan tch benh vong mac do THA va x cng ong
mach
THA
X cng ong mach
Tieu ong mach
Mc o Hep chung
Co that Xuat
XuatPhu Phan
xa
anh
Khiem khuyet
Ty le
khu tru huyet
tiet sai
sang M M-TM bat
cheo
M/TM
th
Bnh thng

3:4

1:1 0

o I

1:2

1:1

o II

1:3

2:3

o III

1:4

1:3

o IV

manh mai,
Giong o III
si gan dong xa

nghen +

0
ng vanh
0
manh, cot mau
o
ng vanh
Ep nhe TM
rong, cot mau
o
ng vanh
Ep sup TM
rong day ong
cot mau khong
thay
ng trang
Gap goc, thon
rong day bac dan va mat TM
cot mau khong di M ; dan TM
thay
xa
+
+
Si gan, cot
mau khong
thay

4. BIEN CHNG TIM, THAN VA NAO CUA BENH THA

Ba bien chng chnh cua benh THA la tim, than va nao. Nhieu
benh nhan ch c phat hien THA khi co bien chng mot
trong cac c quan nay.
12

4.1

Bien chng tim cua THA

Cac bien chng tim cua THA bao gom : ph ai that trai kem dan
hay khong dan buong that, suy tim, benh MV, loan nhp va ot
t.
Cac yeu to benh sinh lam ton thng tim trong THA c tom tat
trong bang 5 (15).
Bang 5 : Cac yeu to benh sinh lam ton thng tim trong THA
Than kinh hormone

Hoat hoa he renin-angiotensin-aldosterone

Tang hoat giao cam
Tang san xuat hoac giam thoai hoa
cac phan t sinh hoc (TD : angiotensin II,
cytokins)
Huyet ong
- Tang sc can mach ngoai vi
- Tang sc cang thanh tim
- Giam d tr vanh
Mach mau
- Roi loan chc nang noi mac
- Tai cau truc mach
- Giam o gian mach
- Phan ng mach qua mc
- X va ong mach vanh va ong mach
ngoai vi
C tim
- Tai cau truc that trai
- Bieu hien gene thai nhi (Fetal gene
expression)
- Ph ai te bao c tim
- Thay oi chat nen ngoai te bao
(extracellular natrix)
TL : Chim C. Lang, Gregory YH Lip. Compliance of Hypertension : the Heart. In Cardiology, ed
by MH Crawford, JP Dimarco, WJ Paulus. Mosby 2004, p. 490

4.1.1 Ph ai that trai do THA

Trc kia, chan oan ph ai that trai (PTT) trong nghien cu da
vao nh lng that trai sau t vong. Ngay nay, trong nghien cu
va thc hanh lam sang, ph ai that trai co the chan oan
bang cac tieu chuan ECG, sieu am tim 2D hoac TM. Cac phng
tien hien ai, chnh xac hn e chan oan ph ai that trai bao
gom : anh cong hng t, CT scan cc nhanh va sieu am tim 3
chieu. Cac phng tien nay cha pho bien trong thc hanh lam
sang. Bang 6 neu len tieu chuan sieu tam TM chan oan ph ai
that trai da theo nghien cu Framingham (16).

13

Bang 6 : Gii han tren cua that trai theo tieu chuan sieu
am

TL : Levy D, Savage DD, Garrison RJ et al. Echocardiographic criteria for left ventricular
hypertrophy : the Framingham Study. Am J Cardiol 1987 ; 59 : 956-960

PTT benh ly thng khong gay ra trieu chng c nang trong

nhieu nam, trc khi bieu hien bang trieu chng suy tim hoac
ot t. o nhay cam cua ECG trong chan oan PTT cao > 90%,
tuy nhien o ac hieu ch 20-40% ; ngc lai o nhay cam cua
sieu am trong PTT la > 80% va o ac hieu > 80% (15). Sieu am
tim con hu ch e chan oan nguyen nhan khac ngoai THA cua
PTT (TD : benh van tim, benh tim bam sinh, benh c tim ph ai).
Tat ca cac thuoc ieu tr THA, ngoai tr minoxidil va hydralazine,
eu co hieu qua giam ph ai that trai. Tuy nhien kha nang
giam PTT gia cac thuoc co the khac nhau. Nghien cu LIVE (17)
chng minh kha nang giam PTT cua li tieu co tnh dan mach
indapamide cao hn enalapril trong ieu tr THA. Nghien cu LIFE (18)
chng minh losartan co hieu qua hn atenolol.
4.1.2 Suy tim do THA
THA n oc, khong ieu tr co the dan en suy tim. Tan suat suy
tim do THA ng hang th 2 sau benh ong mach vanh (MV). THA
cung la yeu to nguy c a en benh MV, loan nhp tim t o
dan en suy tim. THA dan en roi loan chc nang tim, sau o suy
tim co the qua cac giai oan sau :
-

Roi loan chc nang tam trng that trai (TD : do ph ai that)
Roi loan chc nang tam thu TT khong trieu chng c nang kem
PTT ong tam
Dan TT khong trieu chng c nang kem ph ai lech tam TT
Roi loan chc nang tam thu TT co trieu chng c nang kem
ph ai lech tam TT va dan ln TT
14

Tien trien cua hnh dang TT trong suy tim c bieu hien trong hnh 5.
Hnh 5 : Tien trien hnh dang that trai trong suy tim

TL : Chim C Lang, Gregory YH Lip. Complications of Hypertension : the Heart. In Cardiology,

ed. by MH Crawford, JP DiMarco, WJ Paulus. Mosby 2004, 2nd ed, pp. 490-500

Hnh 6 : ng cong bieu hien ap lc - the tch trong roi

loan chc nang tam thu va roi loan chc nang tam trng
that trai

TL : Chim C Lang, Gregory YH Lip. Complications of Hypertension : the Heart. In Cardiology,

ed. by MH Crawford, JP DiMarco, WJ Paulus. Mosby 2004, 2nd ed, pp. 490-500

15

Roi loan chc nang tam trng TT (RLCNTrTT) thng khong co

trieu chng c nang. Tuy nhien RLCNTTrTT co the la nguyen nhan
cua 40% suy tim co trieu chng c nang va thc the. Tan suat
chung cua suy tim sung huyet kem chc nang tam thu TT bnh
thng la 11-83% benh nhan THA va 5-67% benh nhan benh
MV (15).
Chan oan suy tim do THA bao gom :
-

Chan oan xac nh suy tim sung huyet da theo tieu chuan
Framingham hay tieu chuan Chau Au

Xac nh co tien s THA hoac ang b THA. Can chu y la khi

suy tim nang, HA co the khong cao nh khi chc nang tam thu
that trai con tot. Soi ay mat rat hu ch e chan oan co
THA va mc o x cng ong mach.

Loai tr cac nguyen nhan suy tim khac bang trieu chng lam
sang va nhat la can lam sang : benh van tim, benh c tim,
benh mang ngoai tim, benh tim bam sinh va benh MV. Sieu
am tim rat co gia tr trong phan biet cac nguyen nhan suy tim,
ngoai tr benh MV. Chan oan phan biet suy tim do THA va suy
tim do benh MV can sieu am tim Dobutamine hoac oi khi can
chup MV.

ieu tr suy tim do THA cung theo cac quy trnh cua ieu tr suy tim
tam thu va suy tim tam trng. Can at muc tieu ieu tr THA. Can
chu y en benh noi khoa khac ket hp trong THA. UCMC, chen thu
the AG II va li tieu la cac thuoc hang au trong ieu tr. Khi can
s dung c che calci, nen s dung amlodipine. Co the s dung
chen beta, va ha huyet ap, va cai thien chc nang tim. Ch
nen bat au lieu thap va s dung 1 trong 3 thuoc chen beta a
co nghien cu trong ieu tr suy tim : bisoprolol, carvedilol va
metoprolol.
4.1.3 Cac bien chng tim khac do THA
THA la mot trong cac yeu to nguy c chnh cua BMV. Chan oan
va ieu tr BMV c e cap en trong cac chng
Loan nhp tim do THA bao gom loan nhp nh va loan nhp that. THA
la mot trong 4 nguyen nhan chnh cua rung nh. Cac loan nhp that
thng gap bao gom ngoai tam thu that va loan nhp nhanh that.
Nen s dung chen beta ieu tr THA trong trng hp co kem
bien chng loan nhp. Day that trai do THA la mot yeu to nguy c
oc lap cua ot t. ot t do THA phan ln do loan nhp that,
cung co the do huyet khoi trong MV xay ra do tnh trang tang tao
huyet khoi cua THA (19).
4.2

Bien chng than cua THA

16

THA la mot trong cac nguyen nhan thng gap cua suy than giai
oan cuoi (ESRD-end stage renal disease). Can chu y la THA co bien
chng than, co the co them bien chng day that trai va/hoac
benh MV.
Cac ong mach nho va ong mach vao vi cau than thng b
ton thng do THA. Cac thng ton mo hoc bao gom : x cng ong
mach hyaline hoa, tang sinh va ph ai noi mac va hoai t dang
fibrin (hnh 7). Do ton thng au tien cua than do THA xay ra
ong mach nho trc vi cau than, cac bien oi vi cau than
va cau truc sau vi cau than se la cac bien oi thieu mau cuc
bo (hnh 8).
Hnh 7 : Vi cau than trong x cng ong mach than do THA

TL : Sica DA. Complications of Hypertension : the Kidney. In Cardiology, ed. by MH Crawford,

JP DiMarco, WJ Paulus. Mosby 2004, 2nd ed, pp. 501-510

Hnh 8 : Vi cau than thieu mau cuc bo trong x cng than

lanh tnh (benign nephroscleroses)

17

TL : Sica DA. Complications of Hypertension : the Kidney. In Cardiology, ed. by MH Crawford,

JP DiMarco, WJ Paulus. Mosby 2004, 2nd ed, pp. 501-510

Sinh ly benh cua ton thng than do THA c tom tat trong hnh 9.
Can chu y la THA dan en ton thng than, ngc lai benh ly
than cung lam THA. ngi THA dang khong trung (giam HA) ve
em (non nocturnal dipper), se co bien chng day that trai va
bien chng than nhieu hn benh nhan THA co trung ve em
(nocturnal dipper).
Hnh 9 : Cac c che lam gia tang benh than tien phat do
THA (20)
Benh than
tien phat

THA

X cng
tieu ong
mach than
TMCB vi cau
than
X cng chung
than

Tang ap lc
vi cau than

X cng vi cau
than khu tru

Nephron thch
ng

Ph ai vi cau
than

Mat nephron
TL : Sica DA. Complications of Hypertension : the Kidney. In Cardiology, ed. by MH Crawfor,
JP DiMarco, WJ Paulus. Mosby 2004, 2nd ed, pp. 501-510

18

Angiotensin II ong vai tro chnh trong suy than do THA. Cac tac dung
cua AG II lam mat cac nephron dan en suy than (hnh 10).

19

Hnh 10 : S mat nephron do angiotensin II (20)

Angiotensin
II

Hoat hoa
ai thc
bao

Tieu protein

san xuat
Cytokine

TGF- va
ECM

Ap lc thuy
tnh mao mach vi
cau than

PAI-I

Aldosterone

thoai hoa
ECM

Te bao noi mac

va gian bao chu
lc cang/stress
Viem

Ton thng trc

tiep te bao vi
cau than

Lang ong
ECM

Si hoa vi cau
TGF- : transforming growth factor
(yeu
than
vato
ketang
ong trng )
ECM : extra cellular natrix (chat than
nen ngoai te bao)
PAI-1 : plasminogen-activator inhibitor-1 (chat c che hoat hoa plasminogen 1)

TL : Sica DA. Complications of Hypertension : the Kidney. In Cardiology, ed. by MH Crawford,

JP DiMarco, WJ Paulus. Mosby 2004, 2nd ed, pp. 501-510

X hoa than lanh tnh (hoac benh than do THA hoac x hoa benh
than do THA) thng khong co trieu chng c nang.
Benh thng bat au t tuoi > 50, thng benh nhan nam va
ngi da en. giai oan au chc nang than cha giam, can
lang thng bnh thng, co the co vi am nieu. Mot khi co
protein nieu cao (> 1g/24 gi), can ngh ti nguyen nhan benh
than khac vi x hoa than do THA. Creatinine mau thng khong
tang cho ti khi o loc cau than xuong di 30%.
Cac yeu to sau giup chan oan x hoa than do THA :
- Khong co benh than tien phat
- Tien s gia nh khi phat THA t tuoi 25-45
- Chung toc da en My
- THA o 2-3 keo dai
- Khong ap ng huyet ong do than khi an nhieu protein hoac
truyen acid amin
- Tang acid uric mau
- Chng c ton thng vong mac do THA
- Co PTT
- Khi phat THA trc protein nieu
20

Sinh thiet than : mc o si hoa va thieu mau vi cau than

tng hp vi mc o benh ly tieu ong mach

Thuoc ha HA chnh trong ieu tr THA co bien chng than la UCMC

hoac chen thu the angiotensin II. Thng phai phoi hp > 2 thuoc
ha HA mi at muc tieu HA.
Muc tieu HA ay la < 130/80 mmHg, can s dung va phan phoi
thuoc sao cho co hieu qua bao ve HA suot 24 gi. S dung li
tieu phoi hp UCMC rat co hieu qua.
Khi o thanh thai creatinine > 30 ml/phut, co the dung thiazide ;
thap hn can dung furosemide. Co the phoi hp vi li tieu gi
kali nh amioride, triamterene va spironolactone. Khong nen dung c
che calci n oc trong ieu tr THA co bien chng than (21).
4.3

Bien chng nao cua THA : ot qu

Khoang 80-85% ot qu la nhoi mau nao, ch 10% la xuat huyet

nao, con lai la xuat huyet di mang nhen. THA la yeu to nguy
c chnh cua ot qu. Cac yeu to nguy c khac la ai thao ng,
ieu tr hormone thay the, rung nh, nghien nang thuoc la, uong
nhieu ru. Cha co chng c ro ve lien quan gia roi loan lipid
mau va ot qu.
THA dan en bien oi hnh dang cac mach mau nao va bien oi
huyet ong tuan hoan nao. Cac mach mau ln, cac cho chia
nhanh tr nen ph ai, tai cau truc, do o lam thay oi tuan
hoan nao.
THA la yeu to nguy c chnh cua XVM. XVM mach mau nao
thng xay ra goc ong mach canh va ong mach cot song,
ong mach nen va luc giac Willis, cung MC. THA cung lam
tang tao huyet khoi (tnh trang tang ong) do bat thng ong
mau, tieu cau va roi loan chc nang noi mac.
THA cung hay phoi hp vi nhoi mau nao nho dang lo khuyet
(lacunar infarcts), chan oan xac nh bang anh cong hng t.
Nhoi mau nao dang lo khuyet chiem en 25% nhoi mau nao.
Co tng quan gia HA va tan suat mi mac ot qu. Nghien cu
gop Prospective Study Collaboration (22) da tren 45 nghien cu, bao
gom 450.000 nam n, theo doi trung bnh 16 nam cho thay co lien
quan chat che gia mc o HA tam trng vi ot qu (hnh 11).
Tng quan gia HA vi ot qu gap 10 lan ngi tre < 45 tuoi ;
tuy nhien ch gap 2 lan ngi > 65 tuoi (hnh 12).

21

Hnh 11 : Nguy c tng oi ot qu da theo HA tam trng :

tang 10mmHg HAttr, nguy c ot qu tang gap 1,84 lan

TL : SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug

treatment in older persons with isolated systolic hypertension. JAMA 1991 ; 265 : 3255-3264

Hnh 12 : Tng quan gia ot qu va tuoi theo mc HA tam

trng : tng quan gia HA tam trng vi tuoi tre cao hn
ngi ln tuoi

TL : MacMahon S, Peto R, Kupler J et al. Blood pressure, stroke and coronary heart disease.
Part 1 Prolonged differences in blood pressure : prospective observational studies corrected
for the regression dilution bias. Lancet 1990 ; 335 : 765-774

Chan oan ot qu da vao kham lam sang. Chan oan phan

biet gia nhoi mau nao va xuat huyet nao da vao CT scan
hoac anh cong hng t so nao.
ECG giup xac nh rung nh. Sieu am 2D-Doppler giup tm mang x
va va huyet khoi trong ong mach canh. Sieu am tim qua thanh
ngc va qua thc quan giup tm huyet khoi trong tim, lo bau duc
thong thng, cac ton thng tim phoi hp.
22

ieu tr THA co the giam tan suat mi mac ot qu. Cac nghien
cu SHEP (24), Sys-Eur (25) va Sys-China (26) chng minh ieu tr THA
tam thu n thuan giam ot qu t vong va khong t vong lan
lt 36%, 42% va 38%. Cha co nhieu nghien cu so sanh, chng
minh s vt troi cua tng loai thuoc trong hieu qua phong nga
ot qu. Cac nghien cu co ien thng dung li tieu hoac chen
beta.
Nghien cu ALLHAT (27) cho thay hieu qua giam ot qu cua
amlodipine va chlorthalidone cao hn lisinopril. Nghien cu LIFE (18) cho
thay losartan hieu qua hn atenolol trong giam ot qu. Nghien cu
HOT (28) chng minh co the giam huyet ap tam trng ti mc <
80 mmHg. Nghien cu cua Palmer va cong s (29) chng minh, mc
HA tam thu giam 1mmHg giup giam 2% ot qu. HA tam thu co the
gi mc < 140 mmHg.
e phong nga tai ot qu, nghien cu PROGRESS (30) da tren
6105 benh nhan chng minh perindopril phoi hp indapamide giup
giam tai ot qu 43%.
5. CHAN OAN NGUYEN NHAN THA (THA TH PHAT)
Ch t 5-10% THA tm c nguyen nhan. Cac nguyen nhan cua
THA ngi ln c tom tat trong bang 7. Nguyen nhan THA
tre em va tre nho c tom tat trong bang 8. Tat ca benh nhan
THA < 35 tuoi eu tm nguyen nhan THA. Benh nhan > 55 tuoi mi
khi phat THA va THA nang ngay can c tm nguyen nhan,
thng la do hep ong mach than.
Bang 7 : Nguyen nhan THA ngi ln
-

Hep ong mach than

Benh nhu mo than
Hoi chng Conn
Hoi chng Cushing
Tang san thng than sinh duc
U tuy thng than
Cng giap hay nhc giap
Hep eo MC
THA lien quan en thai ky
Hoi chng ngng th khi ngu
Do thuoc vien nga thai
Do tang ap lc noi so : bu nao, viem nao, toan mau ho hap

23

Bang 8 : Nguyen nhan THA man tre em

S
-

sinh :
Hep ong mach than hoac huyet khoi ong mach than
Bat thng cau truc than bam sinh
Hep eo MC
Loan san phe quan phoi

Tre < 6 tuoi

- Benh viem va benh cau truc than
- Hep eo MC
- Hep ong mach than
- Bu Wilms
Tre 6-10 tuoi
- Benh viem va benh cau truc than
- Hep ong mach than
- Benh nhu mo than
- THA tien phat
Tre v thanh nien
- THA tien phat
- Benh nhu mo than
TL : Loggie JMH : Hypertension in children. Heart Dis Stroke May/June 1994 ; 147

5.1

Tang huyet ap do benh mach mau than

THA do benh mach mau than thng do hep ong mach than (MT).
ay la nguyen nhan tm c thng gap nhat trong THA. Tan
suat chung khoang 1%, nhng tang en 50% trong quan the chon
loc. THA do hep MT rat quan trong v chan oan c co the cha
khoi.
Hep MT 2 ben cung la nguyen nhan thng gap cua suy than
man (25%).
5.1.1 C che THA do benh mach mau than
Sinh ly benh THA do benh mach mau than c thc hien bi
Goldblatt va cong s (1934) : kep vao 2 ong mach than cua ong
vat (cho), dan en THA.
MT b hep dan en thieu mau cau truc canh vi cau than, lam
tiet renin. Qui trnh nay c tom tat trong hnh (13).

24

Hnh 13 : Bien oi huyet ong tng bc trong s phat

trien THA do benh mach mau than
Thieu mau cuc bo
than
1
Renin

Angiotensin

Aldosterone

1
4

c
che

Huyet
ap

Sc can
mach ngoai
vi

Natri

T ieu
chnh
2
Cung lng
Cung lng
tim
tim
TL : Kaplan NM. Clinical hypertension. Lippincott Williams Wilkins 8th ed 2002, p. 383

5.1.2 Phan loai va tien trien

Hai nguyen nhan thng gap nhat cua THA do benh mach mau
than la ton thng x va ong mach va loan san c si. Mot t
nguyen nhan khac la tui phnh MT, thuyen tac MT, viem MT
(benh Takayasu, viem nut quanh ong mach), boc tach MT, sa
than.
Mot t nguyen nhan ngoai MT gay chen ep la : bu, bu
mau quanh than, si hoa sau phuc mac, tac nghen nieu quan,
nang gia quanh than.
ac iem lam sang va giai phau hoc hai the chnh cua THA do
BMMT c tom tat trong bang 9.

25

Bang 9 : ac iem cua hai the benh chnh cua THA/BMMT

BMMT
Tan suat
tien t nhien
(%)
(nam)

Tuoi

X va M

Phan gan, 2cm; hiem

Tien trien trong 50%
phan xa
trng hp, thng la
nghen hoan toan

80-90

> 50

V tr ton thng

Dien

ong mach than

Loan san c si
Noi mac 1-2

2)

Tre em
Phan gia ong mach Hau het tien trien;
ngi tre
than chnh va cac nhanh
thng co boc tach
hoac huyet khoi (hoac ca

Trung mac 10-20

33%

25-50

Phan xa ong mach than

Tien

trien

trong

chnh va cac nhanh

trng hp; hiem khi
boc tach hoac huyet khoi
Quanh M
1-2
15-30
Phan gia en phan xa
Tien trien trong hau het
MT chnh hoac cactrng hp; thng co
nhanh
boc tach hoac huyet khoi
TL : TL: Kaplan NM. Clinical hypertension. Lippincott Williams Wilkins 8th ed 2002, p 385

Bang 10 : Tan suat don tien trien en benh than thay oi

theo mc hep ong mach than

TL: Circulation 1998a; 98: 2866-2872

26

Hnh 14 : Chup mach can quang 3 the loan san c si gay

THA

NOI
MAC

TRUNG MAC

5.1.3 Bieu hien lam sang

QUANH ONG
MACH

ac iem lam sang cua THA/BMMT c tom tat trong bang 11.
Bang 11 : iem mau chot ve lam sang THA/BMMT

Benh s:
* Khi phat THA < 30 tuoi hoac > 50 tuoi
* Khi phat ot ngot THA
* THA nang hay khang tr
* Trieu chng x va ong mach ni khac (ngoai than)
* Gia nh khong co tien s THA
* Nghien thuoc la
* Chc nang than / UCMC
* Phu phoi cn tai phat
Kham thc the:
* Am thoi/ bung (46% trng hp)
* Cac am thoi khac
* Ton thng vong mac nang
CLS:
* Cng Aldosterone th phat
- Renin huyet tng cao
- K+ thap Na+ thap
* Protein nieu, thng va phai
* Creatinine mau cao
* Kch thc 2 than cach biet > 1,5cm (sieu am)

TL: McLaughlin K et al. BMJ 2000; 320: 1124 - 1127

Am thoi bung nghe c trong 46% THA/BMMT, trong khi ch 9%

THA tien phat. oi khi THA/BMMT co bieu hien cng aldosterone
(kali mau thap), tieu protein co the nhieu giong hoi chng than
h bien, a hong cau va roi loan lipid mau.
Benh than do thieu mau cuc bo (TMCB) co the hien dien
THA/BMMT. Benh nhan b roi loan chc nang than, thng do
nghen ong mach than 2 ben. ngi cao tuoi, ay la nguyen
nhan cua 38% trng hp benh than giai oan cuoi. Rat can c
chan oan nguyen nhan nay v ieu tr tai lu thong mach (phau
thuat, nong MT) co the giup giam ca THA lan suy than.
Cac trng hp sau can ngh en THA do BMMT hai ben (31) :
27

Phu n tre co THA nang (thng do si hoa mach mau)

THA kem uree mau cao, co nhieu cn phu phoi cap
Tat ca benh nhan THA co dien tien suy than nhanh ma khong
co chng c benh nieu tac nghen
Benh nhan co chc nang than giam nhanh khi ieu tr THA
bang UCMC hay thuoc khac
5.1.4 Chan oan

Thc hien cac trac nghiem can lam sang giup chan oan
THA/BMMT can da vao kha nang thap, kha nang trung bnh hay
kha nang cao cua benh (32). Cac khai niem nay c tom tat
trong bang 12.
Bang 12 : Trac nghiem chan oan THA/BMMT

Kha nang thap (khong lam trac nghiem) THA t nhe en va phai;
khong co mau chot lam sang

Kha nang trung bnh (lam cac trac nghiem khong xam nhap)
* THA nang(HA ttr > 120 mmHg)
* THA khang vi ieu tr chuan
* Khi phat ot ngot THA va phai en nang tuoi < 30 hoac > 50
* THA kem am thoi bung hay vung hong
* THA nang va (HA ttr > 105 mmHg) ngi hut thuoc la, co chng c
benh mach tac
nghen hoac b/n co creatinine mau cao
* Bnh thng HA bang UCMC hoac chen thu the AGII/ THA nang va en
nang

Kha nang cao (can xem xet chup mach mau)

* THA nang (HA ttr > 120mmHg) kem suy than tien trien hoac khang vi
ieu tr tch cc
(ac biet b/n hut thuoc la hoac co benh tac nghen mach ni
khac)
* THA tien trien hoac ac tnh (ay mat o III hay IV)
* THA kem mi tang creatinine mau, khong cat ngha c hoac do s
dung UCMC, hoac
chen thu the AGII
* THA nang va en nang kem kch thc hai than khong bang nhau
TL: Kaplan NM. Clinical hypertension. Lippincott Williams Wilkins 8th ed 2002, p 389

Cac trac nghiem thc hien tren benh nhan nghi THA/BMMT bao
gom : cac trac nghiem giup khao sat ti mau than (chup than
co can quang van toc nhanh, xa ky than vi technetium 99 DTPA,
xa ky than sau captopril), cac trac nghiem lng nh phong thch
renin (t dung) va cac trac nghiem hnh anh ve ong mach than
(sieu am Doppler mau, CT xoan oc, anh cong hng t, sieu am
trong long mach than, chup mach mau than). Chup mach mau
than van c coi la tieu chuan vang trong chan oan THA do
BMMT.
Kha nang cua cac trac nghiem khao sat he mach mau than
c trnh bay trong bang 13.
28

Bang 13 : Kha nang cua cac trac nghiem khao sat he

mach mau than
Phng phap
Hnh anh Ti mau Chc nang
luan
mach
than
loc cau than
Xa ky than kem
bnh thng t ngh en
Captopril

+++

++

Chup ong mach

+++
nguy c cua catheter
than
Sieu am Doppler
++
++
van toc dong chay; khao sat

++

> 2mg/dL
+

khong

tin

cay

khi

Tieu chuan vang:

va chat can quang

u iem: o chnh xac
c nhieu lan; re, co the tien
oan hieu qua ieu tr
Nhc iem: chu quan, khong hp

cho mach mau

Anh cong
++
++
hng t
nang than;
mau nho
CT xoan oc
+++
+
rat ro; bao gom khao sat tnh

u iem: tien dung, neu

benh MMT
Nhc iem:

creatinine mau

Ban

nho

u iem: khong oc
Nhc iem: t thong tin ve chc
khong giup c vi mach
+

u iem: anh 3 chieu

mach
Nhc iem: can chat can quang
TL: Kaplan NM. Clinical hypertension. Lippincott Williams Wilkins 8th ed 2002, p 394

S la chon phng tien can lam sang trong chan oan con can
chu y en chc nang than bnh thng hay suy than.
Bang 14 : La chon can lam sang giup chan oan
THA/BMMT

B/n co chc nang than bnh thng:

* Trac nghiem au tien:
- xa ky than, xa ky than sau captopril
- sieu am MT
* Neu dng nghiem:
- CT xoan oc hoac Anh cong hng t
- CT xoan oc > Anh cong hng t: nhanh xa MT
- Anh cong hng t > CT xoan oc: phan gan MT

B/n co suy chc nang than t nhe en nang va (creatinine mau #

2,3mg/dL): nen chon anh cong hng t thay v CT xoan oc (chat can
quang oc cho than)

B/n co suy than nang:

* Xa ky than va sieu am Doppler: t hieu qua
* Can Anh cong hng t
* Neu khong co: chup MT hoac CT xoan oc (can tnh en nguy c oc

than)

29

5.1.5 ieu tr
ieu tr THA/BMMT bao gom : ieu tr noi, tai tao ong mach than
qua da (nong kem stent) va phau thuat tai lu thong mach than.
Tien bo hien nay cua can thiep ong mach qua da giup ch nh
phau thuat ong mach than ngay cang hiem. Tai lu thong ong
mach than cang sm cang tot, giup giam hoac khong can
thuoc ieu tr THA va giup bao ve than.
Thuoc hieu qua nhat trong ieu tr noi THA/BMMT la c che men
chuyen va chen thu the AG II. Can chu y la hai thuoc nay se
lam suy than neu benh nhan b nghen ong mach than 2 ben.
c che calci cung co hieu qua giam tng ng UCMC trong ieu
tr THA/BMMT. Du ieu tr noi khoa giup on nh HA, can can nhac
ngi benh co can tai lu thong ong mach than khong.
Trc thi ky stent, nong MT bang bong co the co tai hep 25%
trong 1 nam. T thi ai stent, ket qua tot hn nhieu (33) (34).
Phau thuat tai ti mau than co ty le thanh cong 80-90%, tuy
nhien t vong ti 5% va can phau thuat vien co kinh nghiem.
Co the can phau thuat bac cau MV hoac phau thuat g bo
noi mac ong mach canh trc hoac cung luc phau thuat ong
mach than.
Sau ghep than, co the hep MT ngay lo vao cua MT. ay nong
MT la ch nh au tien.
Cha co nghien cu ln va tien cu so sanh 3 phng phap ieu
tr neu tren. benh nhan THA/BMMT do si hoa mach than, ap
ng ieu tr noi tot hn do x va ong mach. THA/BMMT do x va
ong mach se ap ng vi UCMC, chen thu the AG II va c che
calci trong nhieu nam. Nong ong mach than kem stent la ieu tr
chon loc benh nhan khong ap ng ieu tr noi hoac chc
nang than giam dan.
Hnh 15 : Qui trnh ieu tr benh nhan nghi co hep MT (32)

30

Bieu hien lam sang phu hp

hep MT
Co
Trac nghiem
khong xam nhap
(sieu am, anh
cong hng t ;
CT xoan oc)
Co hep MT

Hep mach mau 1

than kem ti
mau than khong
oi xng

Khong

Khong hep MT

Theo doi
- ieu tr yeu to
nguy c

Hnh anh xa ky e
lng nh dong
chay/ moi than
Hep mach mau 1
than kem ti
mau than oi
xng

Nghen MT 2
ben

Theo doi; ieu tr

YTNC
Lng nh co can
tai ti mau (nong,
bac cau)
TL: Safian RD et al. N Engl J Med 2001; 344:431-442

31

5.2

THA do benh nhu mo than

Benh than man tnh la nguyen nhan thng gap nhat cua THA
th phat, tan suat 2-5% tren toan bo benh nhan THA. THA la
nguyen nhan hang th 2, sau ai thao ng cua benh than giai
oan cuoi can loc than (35).
Bang 15 : Cac benh nhu mo than dan en THA

Benh nang than (cystic renal disease)

Benh than a nang (Polycystic Kidney disease)
Benh nang tuy than (Medullary cystic disease)
Benh vi cau than
Viem vi cau than cap
Viem vi cau than man
Viem than ke (Interstitial nephritis)
X hoa than (Nephroslerosis)

Bang 16 : Ch so bnh thng cua chc nang than

Ch so bnh thng
Blood urea nitrogen (BUV)
Serum creatinine
Nam
N
o thanh thai creatinine
Nam
N

5 to 22 mg/dL (1.8 to 7.9 mmol/L)

0.5 to 1.3 mg/dL (40 to 110 mol/L
0.5 to 1.1 mg/dL (40 to 100 mol/L
110 to 150 mL/phut (1.83 to 2.5 mL/s)
105 to 132 mL/phut (1.75 to 2.2 mL/s)

Tnh o thanh thai

Creatinine clearance =
[creatinine nc tieu (mg/dL) x lng nc tieu
(ml)] /
[creatinine mau (mg/dL) x thi gian lay nc tieu
(phut)]
Cong thc c lng o thanh thai creatinine
Nam = [(140 - tuoi) x can nang (kg)] / [72 x creatinine mau (mg/dL) ]
N = [(140 tuoi) x can nang (kg)] / [72 x creatinine mau (mg/dL) ] x 0.85
Tai lieu : Kassirer JP. Clinical evaluation of kidney function-glomerular function. N Engl J
Med. 1971 ; 285 : 385-389
Rakel RE, ed Textbook of Family Practice. 4th ed. Philadelphia, PA : WB Saunders;
1990

5.2.1 ac iem lam sang cua THA do benh nhu mo

than
Cac iem c ban lam sang e chan oan benh nhu mo than bao
gom (36) :
-

Nhiem trung tieu tai dien nhieu lan, ac biet ngi tre,
gi y d tat bam sinh bang quang va/hoac benh than trao
ngc.

S dung nhieu thuoc giam au gay oc than (TD : Phenacetin)

32

Xem xet cac xet nghiem chc nang than co t trc (TD :
uree mau, creatinine mau, tong phan tch nc tieu), giup
phan biet benh than man hay cap.

Tien s uong ru lau gi y kha nang nhiem oc ch.

Benh vong mac do ai thao ng (T) u e chan oan

benh than do T benh nhan co hoi chng than h.
Am thoi bung hay vung hong (ac biet am thoi tam trng)
gi y benh ong mach than hay d tat ong tnh mach

Protein nieu la dau hieu gi y benh vi cau than

Tru hong cau luon luon la dau hieu cua viem vi cau than

Bang 17 : Cac iem c ban ve kham thc the giup chan

oan benh nhu mo than

Dau hieu
Y ngha
Phu quanh hoc mat
Lng dch ngoai te bao gia tang
Phu chi di hoac phan di cua lng
Ran
Tai (Pallor)
Thieu mau suy than man
Am thoi tam thu
Am thoi chc nang
Am thoi tam trng
Tien s viem mang ngoai tim
Tieng co mang tim
VMNT do uree mau cao
Giam cam giac s hay phan xa Benh than kinh do uree mau
cao
Khoi lng c giam
Benh c do uree mau cao

Tai lieu : Hypertension Primer 2nd ed 1999 AHA, p.320

5.2.2 Chan oan THA do benh nhu mo than

Benh nhan b benh nhu mo than thng co trieu chng suy
than, protein nieu va tieu ra mau. Cac kham nghiem lam sang
thng gi y benh nhu mo than dan en THA. Chan oan THA do
benh nhu mo than can xac nh bang can lam sang.
Cac xet nghiem ve uree mau (BUN : blood urea nitrogen), creatinine
mau va o thanh thai creatinine giup chan oan suy than.

33

Hnh 16 : Tng quan gia creatinine mau, BUN va o loc cau

than

Tai lieu : Kassirer JP. Clinical evaluation of kidney function-glomerular function. N Engl J
Med. 1971 ; 285 : 385-389

Hai xet nghiem c ban giup phan tch benh nhu mo than la sieu
am than va tong phan tch nc tieu. Qui trnh chan oan benh
nhu mo than da vao sieu am than va tong phan tch nc tieu
c trnh bay trong bang 18.

34

Bang 18 : Qui trnh chan oan benh nhu mo than

Nan
g

Nghen nieu
quan

Benh nang
than
Than a nang
Nang tuy
than
Khao sat
nieu khoa

Than nho, am, khong

nghen

Benh than giai oan

cuoi

SIEU AM
THAN

Bnh thng

SUY THAN
PHAN TCH NC
TIEU
TIEU MAU

(Am)
Khao sat khoa
nieu khoa
Mau nc
tieu au tien
(buoi sang)

Benh vi cau
than
Benh mo ke
than
Hoai t ong
than cap
Benh than
IGA khoa
Tieu Protein
t the
ng

Khong
Protein
3.5 Grms
Tru hong
cau

TIEU PROTEIN
(+SSA Neg
Dipstick)

(SSA+Dip)
(Albumin)

24Hr
Urine
Protein

Sinh
thiet
than

3.5 Grms
than h

H/c

ien di huyet
thanh & Protein

Benh mo
3.5 Grms
Khong Tru ke
X Primer.
hoa Ed by JL
cau
TL : Moore MA.Loan
Evaluation
In Hypertension
Proteinof Renal Parenchymal Disease.hong
nd
than
Izzo, H.R. Black.
American Heart Association 2 ed 1999, p. 320-322
mau

Lng nh protein nieu :

Que th nhung vao nc tieu giup phat hien albumine nieu khi
hien dien nong o > 30mg%. e phat hien protein nieu, can
th vi sulfosalicylic acid, t nc tieu 24 gi. benh nhan
khong T, chan oan protein nieu khi nong o > 150mg/24 gi.
Dang sm nhat cua benh than do T la microalbumin nieu (30300mg/24 gi albumin nieu). Khong dung que th thong thng e
phat hien microalbumin nieu. Khi protein nieu > 3,5g/24 gi co ngha
benh nhan b hoi chng than h. Benh nhan co protein nieu, can
nh lng protein nieu moi nam e lng nh tnh trang benh vi
cau than. Benh nhan co protein nieu, can khao sat tm benh
T, benh chat keo, a u tuy (multiple myeloma) va o hoat tnh cua
bo the trong huyet thanh.
35

Benh vi cau than : Benh vi cau than co the bieu hien bang 5
hoi chng : protein nieu n oc, tieu mau vo can, hoi chng
than h, hoi chng viem than hoac suy than. Khi benh nhan co
tieu mau, can khao sat nieu khoa. Neu khong co benh nieu
khoa (TD : soi than, bu bang quang, viem bang quang ) va
chc nang than bnh thng ; co the la benh than IgA. Tru hong
cau la dau hieu viem ong mach vi cau than kem xuat huyet
trong ong than. Nhieu trng hp can sinh thiet than e chan
oan xac nh loai vi cau than.
Benh than mo ke (Interstitial renal desease) : Benh than mo ke
c chan oan bang hoi chng suy than (thng khong thieu
nieu), tien s benh mo ke (thng do thuoc) va tong phan tch
nc tieu bnh thng (rat can). Protein nieu cua benh nhan
thng < 1g/ngay. S hien dien cua eosinophil trong nc tieu la
chng c benh than mo ke do thuoc hay "d ng".
X hoa than (Nephrosclerosis) : X hoa than benh nhu mo than
thng do benh man tnh mach mau nho cua than. Thng xay ra
benh nhan THA va benh nhan cao tuoi. Benh nhan thng co
trieu chng suy than, tien s THA, protein nieu <2g/ngay, tong
phan tch nc tieu bnh thng. Sieu am than giup thay 2 than
can xng bnh thng hay hi nho, nhng o phan am echo tang
nhe.
Benh than giai oan cuoi (ESRD : end-stage renal disease) : Benh than
giai oan cuoi c chan oan khi benh nhan co uree mau cao,
phosphor huyet thanh >5,5mg/dL, thieu mau, co protein nieu, co
nhieu tru va sieu am thay than nho, am ac va khong b
nghen.
5.2.3 ieu tr THA do benh nhu mo than
Qua tai the tch trong long mach la yeu to benh sinh chnh
benh nhan THA do benh nhu mo than ; do o han che muoi, s
dung li tieu, neu can lay bt dch bang loc than rat quan trong
trong ieu tr.
Tang tiet renin dan en co mach, nc va muoi cung la yeu
to benh sinh quan trong trong THA do benh nhu mo than. e ieu
tr THA cac benh nhan nay, can dung c che men chuyen
hoac chen thu the angiotensin II. oi khi can cat than 2 ben e
giam tiet renin, benh nhan se song nh loc than.
Mot so iem c ban ve ieu tr THA tren benh nhan suy than
man :
-

Suy than man lam tien trien nang THA ; ngc lai THA khong
kiem soat c lam giam nhanh kha nang loc cau than.
36

Kiem soat hieu qua HA la thiet yeu e ngan chan hoac

cham lai s chuyen t suy than man thanh benh than giai oan
cuoi (ESRD)

Li tieu quai thng rat can thiet e kiem soat HA giai oan
tien ESRD

ieu tr khong thuoc hay thay oi loi song benh nhan THA do
suy than man co khac so vi benh nhan khong suy than man.
ay, han che muoi la quan trong nhat ; van ong the lc kho
thc hien. ieu tr bang thuoc can khi au lieu thap, nang
dan lieu. Thuoc au tien nen s dung la UCMC hoac chen thu
the angiotensin II. Nghien cu GISEN (38), s dung UCMC (Ramipril)
ieu tr THA cho thay kha nang lam cham suy chc nang than
benh nhan co protein nieu > 3g/ngay. Hieu qua cua thuoc khong
lien quan en mc ha HA ; hieu qua bao ve than cang cao khi
protein nieu cang nhieu. Can than khi s dung UCMC hoac chen
thu the AG II benh nhan co o loc cau than < 30 ml/phut/1,73
m2 DTCT. Khong s dung li tieu thiazide khi creatinine mau > 2,5
mg/dL, thay bang furosemide. Nen s dung chen beta tan trong trong
m nh metoprolol, acebutolol, propanolol (cac thuoc nay chuyen hoa
gan). Thuoc ha ap khac nh chen alpha-beta (TD : labetalol,
carvedilol), chen alpha-1 (TD : prazosin, doxazoein), c che calci, nen
dung phoi hp vi cac thuoc ha ap nhom khac. c che calci
rat co hieu qua trong ieu tr THA tren benh nhan suy than man,
tuy nhien khong nen dung cac thuoc nhom dihydropyridine n
oc, nen phoi hp vi chen beta. Cac thuoc co tac dung tren
alpha-2 trung tam eu co hieu qua trong ieu tr THA/suy than man
(TD : methyldopa, clonidine, monoxidine va rilmenidine).
Khoang 10-15% benh nhan loc than, du tot, van cao HA. Khong
s dung li tieu cac benh nhan nay. Cac thuoc ha ap neu
tren eu co the s dung. La chon thuoc ha ap con can ket
hp vi benh noi khoa i kem (TD : benh MV, ai thao ng ).
Nen gi HA mc <130/80mmHg. Nen cho benh nhan uong thuoc
ha ap vao buoi chieu, ngay 1 lan. Tranh cac thuoc lam kch hoat
than kinh the dch anh hng len tim (tang tan so tim). Can han
che muoi natri va kali, kiem soat can nang.
5.3

THA do benh tuyen thng than

Cac nguyen nhan thng than dan en THA la tang tiet tien
phat aldosterone, cortisol va catecholamine. oi khi, tang tiet
deoxycorticosterone (DOC) xay ra benh tang san thng than
bam sinh (congenital adrenal hyperplasia). Cac phng tien chan oan
trc kia, cho thay tan suat THA do benh tuyen thng than ch
khoang 1% ; tuy nhien vi cac phng tien chan oan hien nay (o
ty le aldosterone huyet tng/hoat tnh renin huyet tng, chup cat
lp ien toan, anh cong hng t), tan suat THA do cng
aldosterone cao hn (co the t 6-8% nguyen nhan THA).
37

5.3.1 Cng aldosterone nguyenphat

Aldosterone la mineralocorticoid hormone chnh, tong hp lp ngoai
vo thng than (lp glomerulosa). Cng aldosterone nguyen phat
do adenoma n oc va lanh tnh xay ra trong 75% trng hp, con
lai la cng aldosterone vo can. trng hp nay tuyen thng
than co the bnh thng (ben ngoai) hoac tang san thng than
2 ben dang vi hat hoac hat ln.
Ngoai
aldosterone,
con
co
deoxycorticosterone
(DOC)
la
mineralocorticoid co tac dung yeu hn, tiet bi lp trong vo thng
than (lp fascilata) va ieu hoa bi ACTH. Aldosterone c ieu
hoa bi angiotensin II va ion kali.
C che THA do cng mineralocorticoids c tom tat trong bang 19.
Bang 19 : C che THA do cng mineralocorticoid
+ Tang Natri mau, tang khoi lng tuan hoan, tang cung lng tim
+ Sau o : tang co mach he thong (do tang hoat he giao cam thng than)
+ Tang si hoa c tim

Bang 20 : Nguyen nhan THA do cng mineralocorticoid

+ Cng Aldosterone tien phat :
* Adenoma thng than
* Cng asdosterone vo can (thng than bnh thng hay tang san 2 ben
hay 1 ben)
+ Cng Aldosterone giam c bang Glucocorticod (Glucocorticoid-remediable
Hyperaldosterone)
+ Thieu men 11 va 11-hydroxylase (giam nong o cortisol)
+ Hoi chng tha be ngoai Mineralocorticods (Syndrome of Apparent
Mineralocorticod excess)
+ Hoi chng Liddle (Gia cng Aldosterone) :
* THA, Kali mau thap, Aldosterone mau gan bnh thng
* Benh di truyen, NST thng, troi
* Khiem khuyet kenh Natri ong than
hap thu Natri, bai tiet Kali
+ Hoi chng tha be ngoai Mineralocorticods
* THA, Natri va nc, Kali mau thap, renin mau thap, nong o
Aldosterone mau bnh
thng
* Thng tre em, THA rat nang
* C che : thieu men 11-hydroxysterod deshydrogenase (men oxid hoa cortisol)
+ An nhieu cam thao, nhai thuoc la : bieu
hien tng t cng
mineralocorticoid

5.3.1.1
Chan oan THA do cng aldosterone
nguyen phat
Cac dau hieu sau giup ngh en THA do cng aldosterone nguyen
phat :
- THA kem kali mau thap < 3,2 mEg/l

38

THA kem kali mau bnh thng nhng khi s dung li tieu mat
kali, lng kali mau giam manh kem kali nieu cao (>
30mmol/ngay)

Ty le aldosterone huyet tng/renin huyet tng la mot trac nghiem

tam soat hu ch e chan oan. Khi t le nay > 30, co the ngh
en chan oan cng aldosterone nguyen phat.
Trac nghiem tot nhat e chan oan cng aldosterne tien phat
la o nong o aldosterone trong nc tieu 24 gi, sau 3 ngay an
nhieu muoi natri.

39

Hnh 17 : Nong o nong o kali mau benh nhan cng

aldosterone tien phat so vi benh nhan tang huyet ap vo
can

TL : Atlas of Heart Disease,

Current Medicine 1997, p.6.10

Hnh 18 : Nong o aldosterone nc tieu 24 gi sau 3 ngay

an nhieu muoi natri : chan oan xac nh tot nhat cng
aldosterone tien phat

TL : Atlas of Heart Disease,

Current Medicine 1997, p.6.10

40

Bang 21 : Chan oan sinh hoa giup phan biet adenoma va

cng aldosterone vo can do tang san
Ha Kali
mau

Kali mau bnh

thng

Cho an nhieu
muoi natri

( PRA)

Tang san
xuat
aldosterone
qua mc

Giam nong o
aldosterone t
the ng
18-OHB huyet
tng
Cac xet nghiem xac nh v tr
PAC = Plasma aldosterone concentration

18-OHB = 18-hydroxycorticosterone

TL : Atlas of Heart Disease, Current Medicine 1997, p.6.13

Chan oan xac nh v tr adenoma bang chup cat lp ien toan

co can quang (nhat cat < 3 mm) hoac anh cong hng t.
5.3.1.2
ieu tr THA do cng aldosterone nguyen
phat
Bao gom : ieu tr noi khoa hoac ieu tr ket hp noi ngoai khoa.
Ch nh ieu tr noi khoa khi la tang san thng than hoac la
adenoma nhng nguy c phau thuat cao. Phan ln ieu tr ngoai khoa
la phau thuat qua noi soi. Cac benh nhan nay can ieu tr noi
t 3 en 6 thang trc.
Thuoc chon loc trong ieu tr THA do cng aldosterone nguyen phat
la spironolactone, eplerenon hoac amiloride. Co the ket hp vi li
tieu mat kali nh hydrochlorothiazide hoac furosemide. Lieu lng
spironolactone thng la 100-200mg/ngay. Trng hp HA cha at
muc tieu, co the ket hp vi chen beta, dan mach hoac thuoc
chong giao cam trung tam.

41

5.3.2 THA do hoi chng Cushing

THA xay ra 80% benh nhan hoi chng Cushing. Tng t THA do
cac nguyen nhan noi tiet khac, can phat hien sm nguyen
nhan. Phat hien cham, du a ieu tr het nguyen nhan, THA
van con ngi benh.
Cortisol do tuyen thng than tiet ra co the gan vao thu the
mineralocorticoid, neu khong c men 11 beta hydroxysteroid
deshydrogenase (11-OHSD) chuyen thanh cortisone khong hoat tnh.
Cortisol cung co tac dung kch thch s tong hp chat nen renin va
thu the angiotensin II do o lam THA. Lng cortisol do ngi b hoi
chng Cushing tiet ra vt qua mc trung hoa cua 11-OHSD. Ngoai
cortisol, benh nhan Cushing cung ong thi tang tiet
mineralocorticoids.
Cac dau hieu lam sang cua hoi chng Cushing bao gom : beo
phan than, da kho, yeu c, loang xng va THA. Chan oan loai
tr bang o lng cortisol t do trong nc tieu 24 gi hoac trac
nghiem c che bang dexamethasone.
Co hai cach thc hien trac nghiem c che bang dexamethasone
(39) :
-

o lng cortisol huyet tng vao luc 8 gi sang sau lieu 1mg
dexamethasone luc ngu. Bnh thng nong o cortisol phai < 2
microgram/dL. o ac hieu cua phng thc nay la 87%.

Do lng cortisol huyet tng sau 1 ngay hoac 48 gi s dung

2mg dexamethasone (0,5 mg x 4 lan). o ac hieu cua phng
thc nay la 100%.

Khi trac nghiem nay bat thng, co the lam them trac nghiem
c che bang dexamethasone lieu cao (2mg dexamethasone moi 6 gi
trong 48 gi), sau o o lng cortisol huyet tng va cortisol t do
trong nc tieu. o lng ACTH huyet tng se giup phan biet hoi
chng Cushing do benh ly nao thuy hay do bu tuyen thng
than.
Chup cat lp ien toan hoac anh cong hng t tuyen yen va
thng than giup xac nh benh.
Khoang 2/3 hoi chng Cushing do benh ly nao thuy lam tang
san thng than 2 ben. Hau het la do adenoma tuyen yen, hiem
khi benh ly vung ha oi. Vi phau thuat than kinh xuyen xng
bm chon loc giup giai quyet tan goc benh. hoi chng
Cushing do bu tuyen thng than, ieu tr chnh cung la phau
thuat.
c chan oan va ieu tr sm, hau het benh nhan khong can
ieu tr glucocorticoid thay the va HA tr lai bnh thng.
42

5.3.3 Chan oan THA do u tuy thng than

Khoang 50% benh nhan THA do u tuy thng than co THA tng cn.
Tuy nhien benh nhan co the khong chu y en cn, b bo qua
hoac c thay thuoc chan oan sai la roi loan than kinh tim.
Khoang 50% b THA keo dai (khong THA cn). Do b bo sot cn THA,
mot so benh nhan ch c phat hien benh khi a co bien
chng cua THA : ot qu, benh canh nao do THA, xuat huyet vong
mac.
5.3.3.1

Sinh ly benh

U tuy thng than bat nguon t te bao chromaffin cua he thong

giao cam. Khoang 85% u tuy thng than xay ra ngay tuyen
thng than, trong o 10% ca 2 ben va 10% la ac tnh. Khoang
15% con lai nam ngoai tuyen thng than. U tuy thng than gia
nh nam trong hoi chng MEN (multiple endocrine neoplasia). Hoi
chng MEN-2 di truyen troi tren nhiem sac the 10.
U tuy thng than xay ra tren tuyen thng than thng tang tiet
nhieu epinephrine. ac iem cua benh nhan la THA chu yeu tam
thu va co kem nhieu trieu chng do tang epinephrine nh tim ap
nhanh, toat mo hoi, bng mat va lo lang. U tuy thng than
ngoai tuyen thng than thng tiet nhieu nor-epinephrine. Benh
nhan tang ca HA tam thu va tam trng do tac dung co mach cua
nor-epinephrine, ong thi tim t nhanh, t hoi hop va lo lang.
5.3.3.2 ac iem lam sang
Cac ac iem sau giup ngh en u tuy thng than (10) :
-

Tang huyet ap : keo dai hoac tng cn

+ Thay oi nhieu tr so HA (+ ha HA t the ng)
+ Cn kch phat ot ngot (+ THA) lien quan en
Stress : gay me, chup mach, thai san
Do thuoc : histamine, nicotine, cafeine, chen beta,
glucocorticoids, chong tram cam 3 vong
Tac ong c hoc len bu : tham kham bung (s,
an), i tieu
+ Trng hp bat thng
tuoi tre, thai ky tien s gia nh
Adenomas noi tiet nhieu ni : carcinoma tuy tuyen
giap (MEN-2), bu than kinh niem mac (mucosal
neuromas) MEN-2B
43

Ton thng da than kinh : neurofibromatosis

Trieu chng c nang phoi hp : Cn ot ngot gom nhc au,

hoi hop, bt rt, buon non va oi.

Trieu chng thc the phoi hp : toat mo hoi, tim ap nhanh,

loan nhp tim, tai va giam can
5.3.3.3

Chan oan va ieu tr

Can ngh en mi chan oan c THA do u tuy thng than. Cn

THA kch phat kem cac trieu chng c nang, trieu chng thc the
giup ngh nhieu en benh, nhng thng b bo sot.
Tat ca benh nhan THA tien trien nhanh, ngi ln va tre em can
ngh en THA do u tuy thng than. Lng catecholamine mau cao
co the dan en viem c tim, benh c tim.
Chan oan xac nh da vao o catecholamine nieu hoac
metanephine nieu trong nc tieu 24 gi. e nh lng
catecholamine nieu, benh nhan can kieng c trong 1 tuan le cac
chat sau : tetracycline, methyldopa, labetalol, thuoc la, cac o an
co cha vanille. benh nhan can nh lng metanephrine can
tranh labetalol, cac thuoc tr giao cam, cac thuoc dopaminergic,
chat can quang cha methylglucamine, stress nang nh NMCT cap va
suy tim sung huyet nang (39). Trng hp th nc tieu khong cho
ket qua ro rang, co the o lng norepinephrine huyet tng 3 gi
sau lieu uong 0,3mg clonidine. benh nhan khong u tuy thng
than, lieu clonidine 0,3 mg se c che nor-epinephrine ; ngc lai
benh nhan co u tuy thng than. Chan oan xac nh v tr u tuy
thng than da vao chup cat lp ien toan hoac anh cong
hng t.
Mot khi xac nh c khoi u, ieu tr chnh la phau thuat. Trc
o can on nh huyet ap bang thuoc c che alpha (TD :
pheroxybenzamine, Dibenzyline ) hoac labetalol (Trandate ). Van co
the s dung c che calci trong trng hp THA do u tuy thng
than (40).

44

TAI LIEU THAM KHAO

1.

Lifton RP, Gharavi AG, Geller DS. Molecular mechanisms of human

hypertension. Cell 2001 ; 104 : 545-546

2.

Carter AR, Zhou ZH, Calhoun DA et al. Hyperactive EnaC identifies

hypertensive individuals amendable to amiloride therapy. Am J Physiol
Cell Physiol 2001 ; 281 : C1413-C1421

3.

Kim JR, Kiefe CI, Liu K et al. Heart rate and subsequent blood pressure in
young adults. The CARDIA study. Hypertension 1999 ; 33 : 640-646

4.

Anderson EA, Sinkey CA, Lawton WJ et al. Elevated sympathetic nerve

activity in borderline hypertensive humans : evidence from deriect
intraneural recordings. Hypertension 1989 ; 14 : 177-183

5.

Calhoun DA, Mutinga ML. Race, family history of hypertension and

sympathetic response to cold pressure testing. Blood Pressure 1997 ; 6 :
209-213

6.

Mulvany MJ, Aalkjaer C. Structure and function of small arteries. Physiol

Rev 1990 ; 70 : 921-961

7.

Calhoun DA, Zaman MA, Oparil S. Etiology and pathogenesis of systemic

hypertension. In Cardiology, ed. By Michael H Crawford, John P DiMarco,
Walter J Paulus. Mosby 2004, 2nd ed. pp. 463-471

8.

Gordon RD, Stowasster M, Tunny TJ et al. High incidence of primary

aldosteronism in 199 patients referred with hypertension. Clin Exper
Pharmac Physiol 1994 ; 21 : 315-331

9.

Gally BH, Ahman S, Xu L et al. Screening for primary aldosteromism

without discontinuing hypertensive medications : plasma aldosterone
renin ratio. Am J Kidney Dis 2001 ; 37 : 699-705

10. Kaplan NM. Systemic hypertension : Mechanisms and Diagnosis. In Heart

Disease, ed by. E. Braunwald, DP Zipes, P Libby ; WB Saunders 2001, 6 th
ed, pp. 941-971
11. Chobanian AV, Bakris GL, Black HR et al. Seventh report of the joint
national committee on prevention, detection, evaluation and treatment
of high blood pressure (JNC 7). Hypertension 2003 ; 42 : 1206-1252
12. Guidelines committee. 2003 European Society of Hypertension.
European Society of Cardiology guidelines for the management of
arterial hypertension. Journal of Hypertension 2003 ; 21 : 1011-1053
13. Burt VL, Welton P, Rocella EJ et al. Prevalence of hypertension in the US
adult population. Results from the Third National Health and Nutrition
Examination Survey 1988-1991. Hypertension 1995 ; 25 (3) : 305-313
45

14. Pham G. Khai, Nguyen L. Viet, Pham T. Son va cong s. Tan

suat tang huyet ap va cac yeu to nguy c cac tnh pha
bac Viet Nam 2001-2002. Bao cao tai Hoi ngh Tim mach mien
Trung m rong 2003 Nha Trang.
15. Chim C Lang, Gregory YH Lip. Complications of Hypertension : the Heart.
In Cardiology, ed. by MH Crawford, JP DiMarco, WJ Paulus. Mosby 2004,
2nd ed, pp. 490-500
16. Levy D, Savage DD, Garrison RJ et al. Echocardiographic criteria for left
ventricular hypertrophy : the Framingham Study. Am J Cardiol 1987 ; 59 :
956-960
17. Gosse P, Sheridan DJ, Zannad F et al. Regression of left ventricular
hypertrophy in hypertensive patients treated with indapamide SR 1.5mg
versus enalapril 20mg. J Hypertens 2000 ; 18 : 1465-1475
18. Dahlof B, Devereux RB, Kjeldsen SE et al. Cardiovascular morbidity and
mortality in the Losartan Intervention For End point reduction in
hypertension study (LIFE) : a randomised trial against atenolol. Lancet
2002 ; 359 : 995-1003
19. Lip GYH. Hypertension and the prothrombotic state. J Hum Hypertens
2000 ; 14 : 687-690
20. Sica DA. Complications of Hypertension : the Kidney. In Cardiology, ed.
by MH Crawford, JP DiMarco, WJ Paulus. Mosby 2004, 2nd ed, pp. 501-510
21. Agodoa LY, Appel L, Bakris GL et al. Effect of ramipril vs amlodipine on
renal outcomes in hypertensive nephrosclerosis ; an randomized
controlled trial. JAMA 2001 ; 285 : 2719-2728
22. Prospective Studies Collaboraton. Cholesterol diastolic blood pressure
and stroke 13000 strokes in 450000 patients in 5 prospective cohorts.
Lancet 1995 ; 346 : 1647-1653
23. MacMahon S, Peto R, Kupler J et al. Blood pressure, stroke and coronary
heart disease. Part 1 Prolonged differences in blood pressure :
prospective observational studies corrected for the regression dilution
bias. Lancet 1990 ; 335 : 765-774
24. SHEP Cooperative Research Group. Prevention of stroke by
antihypertensive drug treatment in older persons with isolated systolic
hypertension. JAMA 1991 ; 265 : 3255-3264
25. Staessen JA, Fagard R, Thijs L et al. Randomised double-blind comparison
of placebo and active treatment for older patients with isolated systolic
hypertension. Lancet 1997 ; 350 : 757-766

46

26. Liu L, Wang JG, Gong L et al. Comparion of active treatment and placebo
in older chinese patient with isolated systolic hypertension. J Hypertens
1998 ; 16: 1823-1829
27. ALLHAT Collaborative Research Group. Major cardiovascular events in
hypertensive patients randomised to doxazosin vs chlorthalidone : the
Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack
Trial (ALLHAT). JAMA 2000 : 283 (15) : 1967-1975
28. Hansson L, Zanchetti A, Curthers SG et al. Effects of intensive blood
pressure lowering and low dose aspirin in patients with hypertension
(HOT study). Lancet 1998 ; 351 : 1755-1762
29. Palmer AJ, Bulpitt CJ, Fletcher A et al. Relation between blood pressure
and stroke mortality. Hypertension 1992 ; 20 : 601-605
30. PROGRESS collaboration group. Randomised trial of Perindopril based
blood pressure lowering regimen amongst 6105 individuals with previous
stroke or transient ischemic attack. Lancet 2001 ; 358 : 1033-1041
31. Kaplan NM. Clinical Hypertension. Lippincott Williams & Wilkins, 8 th ed
2002, pp. 381-403
32. Mann SJ, Pickering TG. Detection of renovascular hypertension. State of
the art 1992. Ann Intern Med 1992 ; 117 : 845-353
33. Lederman RJ, Mendelsolm FO, Santos R et al. Primary renal artery
stenting. Am Heart J 2001 ; 142 : 314-323
34. Leertouwer TC, Gussenhoven EJ, Bosch JL et al. Stent placement for renal
artery stenosis : Where do we stand ? A meta-analysis. Radiology 2000 ;
216 : 78-85
35. US Renal Data System. Excerpts from the USRDS 2000 Annual Data
Report : atlas of end stage renal disease in the United States. Am J
Kidney Dis 2000 ; 36 (Suppl 2) : S1-S239
36. Moore MA. Evaluation of Renal Parenchymal Disease. In Hypertension
Primer. Ed by JL Izzo, H.R. Black. American Heart Association 2 nd ed 1999,
p. 320-322
37. GISEN Group. Randomised placebo-controlled trial of effect of ramipril on
decline in glomerular filtration rate and risk of terminal renal failure in
proteinuric, non diabetic nepluopathy. The GISEN Group (Gruppo Italiano
di Studi Epidemiologici in Nefrologia). Lancet 1997 ; 349 : 1857-1863
38. Newell-Price J, Trainer P, Besser M et al. The diagnosis and differential
diagnosis of Cushings syndrome and pseudo-Cushings state. Endoc.
Rev 1998 ; 19 : 647

47

39. Feldman JM Falsely elevated urinary of catecholamine and

metanephrines in patients receiving labetalol therapy. J Clin Pharmacol
1987, 27 : 288
40. Wichaker JC, Goldfarb DA, Bravo EL et al. Successful outcomes in
pheochromocytoma surgery in the modern. J Urol 1999 ; 161 : 764

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