hypertension
DESCRIPTION
Hypertension. Concept: systemic blood pressure increased, target organ damaged(brain,heart , eye, kidney, vessel), metabolism changed Essential hypertension(ET): unknown cause, 95% ,hypertensive disease. Secondary hypertension(ST): known cause, 1- 5%. Epidemiology. - PowerPoint PPT PresentationTRANSCRIPT
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Hypertension• Concept: systemic blood pressure increased, target organ
damaged(brain,heart , eye, kidney, vessel), metabolism changed• Essential hypertension(ET): unknown cause, 95% ,hypertensive disease. • Secondary hypertension(ST): known cause, 1- 5%
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Epidemiology
• Incidence increasing rapidly, 11.26% in >15years old in China in 1999
• incidence different among race, age,sex, area( 城乡,南北,高原,发达地区等)• 知晓率,服药率,控制率 lower
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中国高血压的现状和流行趋势• 1999 年普查 - 患病率 11.26%; 10 年上升 25%
- 90 年代初有高血压患者 9500 万- 目前预计 > 1 亿
• 1998 年 - 脑血管病居城市居民死亡原因第二位, 农村居首位,- 脑卒中的主要危险因素为高血压
• 伴随 - 糖尿病患病率 ; 吸烟率 ; 超重 ; 冠心病
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Pathogenesis of Hypertension• Hereditary and gene hypothesis : 20-40% population have hereditary tendency candidate hypertensive gene 5-8• Environmental factors : hypoweight , overweight, high salt diet, drunk
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Pathophysiology of Hypertension
• Psychological and psychopathic factors • Renin –angiotensin aldosterone system ( RAAS )• Sodium and hypertension• Abnormality of vascular
endothelium ( ET , NO , AngII, PGI2, etc)• Insulin resistance• revascularization• other ( obesity , smoking , drinking , hypocalci
um, hypomagnesium, hypopotassium )
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Pathophysiology of Hypertension
• BP=CO X SVR• CO: blood volume , HR , myocardial contractility• SVR :阻力小动脉结构改变 血管壁顺应性降低 血管的舒缩状态改变
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Clinical Manifestation
• Early: asymptom , great BP variation
headache , dizziness , palpitation , fatigue A2 S4 , aortic area SM• Late: manifestation of complications brain, heart , eye, kidney, vessel damage
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Clinical Manifestation Target organ related to accelerated AS related to BP level
heart angina 、 MI , SD heart failure
Brain TIA , brain thrombosis cerebral hemorrhage encephalopathy
Kidney renal angiopathy renal arteriolosclerosis renal failure
Artery blocking lesion aortic dissection
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Clinical Manifestation
Most common complications are from brain , 4-6 times of AMI 。
Include:TIA , brain thrombosis , brain infarction (包括腔隙性脑梗塞) , encephalopathy , cerebral
hemorrhage 。
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Hypertension and Stroke
• Both SBP & DBP positively related to stroke risk
• DBP< 5mmHg, stroke risk decrease 35 - 40% 。• 不存在这样一个 DBP 的低限水平,低于这一水平时, stroke risk 不再继续下降。• Following the aging , stroke incidence increase rapidly 。
• 血压水平与脑出血和脑梗塞都有相关关系,但似乎与脑出血的关系更陡直一些。
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高血压与冠心病危险性• 血压水平与主要冠心病事件危险有连续正相关关系。• 这种相关的强度约为与中风相关强度的 2/3 。• 未发现有一低限水平,低于这一水平时,冠心病事件的危险性不再继续下降。
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高血压与心力衰竭和肾脏疾病• 心力衰竭的危险性及肾脏疾病的危险性与血压水平有关。• 与没有高血压病史者相比,有高血压史患者的心力衰竭危险性至少增加 6 倍。• DBP 每降低 5 mmHg, 终末期肾脏疾病的危险性至少降低 1/4 。
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Keith-Wagener 眼底分级法• I 级:视网膜动脉变细,反光增强• II 级:视网膜动脉狭窄, AV 交叉压迫• III 级:眼底出血,棉絮状渗出• IV 级:视神经乳头水肿
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Lab
• Blood pressure measurement once-determined, self-determined, ambulatory BP measurement• Lab test: Urine, K+, Cr, Bun, Glu,PRA, Ald,• ECG, UCG, X-ray • Eye ground check
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Ambulatory BP monitoring ( ABPM )
Normal : 2peak 1 trough , 6-8AM , 4-6PM peak , lowest at nightMild,middle degree ET :血压波动曲线与正常类似严重高血压或伴明显靶器官损害,血压昼夜节律消失Normal : 24h average BP<130/80, daytime<135/85 , night time 125/75 night BP lower than day<10%
Disappearance of BP rhythm :white coat hypertension
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诊所血压测量规范• 至少安静休息 5 分钟• 取坐位,测右上臂,肘部与心脏同一水平;首诊测双臂血压;必要时加测立位血压• 使用标准的水银柱式血压计和大小合适的袖带• 测量时快速充气,以恒定速率慢放气 ( 2-6mmHg/ 秒)• 收缩压读数取柯氏音第 I 时相,舒张压读数取柯氏音第
V 时相(消失音)• 血压单位用毫米汞柱( mmHg)• 一般取 2次血压读数的平均值记录
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Diagnosis• SBP 》 140mmHg and /or DBP 》 90mmHg• Good for all adults , children maybe lower 。• 2 or more than twice not in the same day under
non pharmacological condition
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高血压防治指南• JNC - VI: 美国预防 /检测 /评估与治疗高血压全国联合委员会第六次报告
( Arch Intern Med. 1997; 157:2413-2446)
• 1999 WHO-ISH 高血压治疗指南( Journal of Hypertension; Vol 17;No.2; 1999; 151-183.)
• 中国高血压防治指南( 1999 年)(中国高血压防治指南编写专家组)
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高血压与正常血压• 血压水平与心血管危险性呈连续性相关,高血压的定义是人为的。• 很多与血压有关的疾病发生在通常认为是“正常血压”的患者身上。• 关于降低血压水平的效果的证据,大多数来自对高血压患者的研究。• 能否将治疗效果外推到血压水平较低的个体,还不确定。• 有很强的理论基础来预期,降低血压能使没有高血压的高危患者受益,目前正在进行一些研究探讨可能性。
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血压水平的定义和分类分类 收缩压( mmHg) 舒张压 (mmHg)
理想血压 <120 < 80
正常血压 <130 < 85
1级高血压(轻度) 140 - 159 90 - 99
亚组:临界高血压 140 - 149 90 - 95
2 级高血压(中度) 160 - 179 100-109
3 级高血压(重度) >= 180 >= 110
单纯收缩期高血压 >=140 < 90
亚组:临界收缩期高血压 140-149 < 90
注:当收缩压与舒张压属不同级别时,应该取较高的级别分类。
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Clinical Evaluation of hypertension
• Evaluation of BP level• Exclusion secondary hypertension• Evaluation of target organ damage • Other cardiovascular risk factors and other
clinical condition to effect on prognosis
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Common etiology of 2nd hypertension
肾脏疾病: 肾血管疾病: 肾动脉狭窄 肾实质疾病:肾炎,肾盂肾炎,多囊肾内分泌疾病:原醛,库欣综合征,嗜铬细胞瘤等血管病变: 多发大动脉炎,主动脉缩窄颅脑病变:脑肿瘤,颅内高压,脑外伤等妇科疾病:妊高症,口服避孕药药源性: NSAID ,激素, MAO ,拟肾上腺素药物其他: RBC 增多症,高原病,高血钙,药物
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高血压分期( WHO/ISH , 1993 年)一期:无器官损害客观表现二期:至少有一项器官损害表现 左心室肥厚( X 线、心电图、超声)视网膜动脉变窄蛋白尿和(或)血肌酐轻度升高( 106-177μmol/L ) 超声或 X 线示有动脉粥样硬化斑块(颈、主、髂、股动脉)三期:出现器官损害的临床表现心:心绞痛、心肌梗塞、心力衰竭脑:短暂脑缺血发作( TIA )、脑卒中、高血压脑病眼底:视网膜出血、渗出物伴或不伴视乳头水肿肾:血肌酐≥ 177μmol/L、肾功能衰竭 血管:动脉夹层、动脉闭塞性疾病
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Risk factor of cardiovascular disease
• male > 55, female> 65• smoking• Total cholesterol> 5.72mmol/L (250mg/dl)• diabetes• Early cardiovascular family history ( early onset of
CV disease male<55 ; female <65)
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并存的临床情况脑血管疾病• 缺血性卒中• 脑出血• 短暂性脑缺血发作 (TIA)
肾脏疾病• 糖尿病肾病• 肾功能衰竭 (血肌酐 >177mmol/L 或 2.0mg/dL)
心脏疾病• 心肌梗死• 心绞痛• 冠状动脉血运重建 (PTCA,PCI,CABG)• 充血性心力衰竭•左心室肥厚(心电图/超声心动图及 X 线)
血管疾病• 夹层动脉瘤• 症状性动脉疾病•超声或 X 线证实有动脉粥样斑块(颈动脉/髂动脉/股动脉或主动脉)
重度高血压性视网膜病变• 出血或渗出• 视乳头水肿
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Risk stratification of CV disease
血压( mmHg) 其他危险因素 1 级 2 级 3 级 和病史
I 无其他危险因素 低危 中危 高危 II 1-2 个危险因素 中危 中危 极高危 III 》 3 个危险因素 或靶器官损害 高危 高危 极高危 或糖尿病 IV 并存临床情况 极高危 极高危 极高危
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危险性分层的绝对危险与降压治疗的绝对效益 绝对危险 降压治疗绝对效益
危险性 ( 10 年内心血管事件) (每治疗 1000 病人年预防心血管事件数) 分层 10/5mmHg 20/10 mmHg
低危 < 15% <5 < 9
中危 15-20% 5-7 8-11
高危 20-30% 7-10 11-17
很高危 > 30% >10 >17
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Aim to prevent and treatment尽量采用非创伤的方式,使 BP 达标: SBP< 140 mm Hg (糖尿病患者: < 130 mmHg)
DBP< 90 mm Hg ( 糖尿病患者: < 80mmHg)
控制其它心血管危险因素,减少靶器官损害,降低病残率和死亡率。
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1st degree prevention
• 一级预防提供降低高血压及其并发症昂贵的治疗费用的可能。• 可以被广泛接受的治疗方法,可以减少发病率和死亡率。• 多数高血压病人未充分改善其生活方式,或严格坚持药物治疗,以控制血压。• 血压随年龄的增加而升高的情况并非不可避免。• 生活方式的改善可以降低血压。
Arch Intern Med. 1997; 157:2413-2446.
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降压治疗的实施过程• 对高血压患者临床评估后,首先进行危险性水平分层(低危,中危,高危,极高危)• 所有患者都应采用非药物治疗措施• 制定降压治疗计划,确定血压控制目标值- 极高危/高危患者: 开始药物治疗- 中危:除改善生活方式,开始药物治疗- 低危:改善生活方式 6M , BP仍高,开始药物治疗• 治疗随访,调整治疗方案
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Non-medication treatment • 减轻体重, BMI(Kg/m2)<=24
• 采用合理膳食:- 限制钠盐:每人每日 <6克- 减少脂肪:占总热量的 30% 以下- 增加蔬菜/水果和鲜奶- 控制饮酒:每日酒精量 <20克• 增加体力活动和运动• 保持心理平衡• 戒烟• 戒烟限酒,适量运动,心理平衡,合理膳食
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影响降压药物选择的主要因素• 具体患者的心脑血管危险因素状况• 是否有靶器官损害或临床相关病症• 是否有限制某类降压药物使用的临床情况• 是否与其它必须使用的药物有相互作用• 临床试验获得的证据强度• 降压药物供应情况和价格及患者支付能力
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Principle of choosing antihypertension agent• 从低剂量开始治疗,有效但未达目标血压,无副反应,可逐步增加剂量。• 疗效不明显,且有副反应,改用另一类;• 联合用药。(有效控制血压, 70%需联合用药)• 长效制剂,一日一次 ( T/P >50% )。24小时内稳定降压,减少血压变异性,改善治疗依从性。• 固定小剂量复方制剂。• 一旦诊断为原发性高血压,通常要终生降压治疗。终止治疗,最终血压会恢复到治疗前水平。但可调整剂量。
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Anti-hypertensive agents
• Diuretics• ß –blocker• Calcium channel blocker • ACE inhibitor• Angiotensin II receptor blocker
a - blocker
• 固定剂量复方降压制剂
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Anti-hypertensive agents 利尿剂 (diuretics)
• 适应症: 作用和缓, 2-3周达高峰,轻/中度高血压 老年人高血压,收缩期高血压,心力衰竭• 种类:噻嗪类 双氢克尿塞 袢利尿剂 速尿 保钾利尿剂 氨体舒通 吲哒帕胺(寿安泰) • 限制:痛风,血脂异常,糖尿病,,离子紊乱,妊娠• 小剂量可避免低血钾,糖耐量降低和心律失常等不良反应。
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Anti-hypertensive agents ß-阻滞剂 (ß -blocker) Indication : 作用和缓, 1-2周发挥作用, 轻/中度高血压,青中年 合并劳力性心绞痛,心肌梗死后, 快速心律失常,心力衰竭Classification : 1 代:心得安 (propranolol) 2 代:氨酰心安 (atenolol) ,倍他乐克 (metoprolol) , 康可 (bisoprolol) 3 代:卡维地络( carvedilol)Contraindication : 哮喘,慢阻肺,周围血管病 II-III 度心脏传导障碍 代谢紊乱,高血脂,高血糖等Limitation : diabetes(I) , labourer
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Anti-hypertensive agents
Calcium channel blocker,CCB• Indication : mild to severe hypertension, senile hypertension stable angina, peripheral vessel disease
• classification :二氢吡啶类 :速效,长效 维拉帕米 地尔硫卓• Contraindication :非二氢吡啶类-心脏传导阻滞,心力衰竭短效二氢吡啶类-不稳定心绞痛, AMI
( 以上不适用于长效二氢吡啶类)
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Anti-hypertensive agents
ACE Inhibitor• Indication : all type hypertension, heart failure, post
infarction, LV hypertrophy, diabetes mild proteinuria
• Classification :
short :开博通 Long :悦宁定,瑞泰,洛汀新,蒙诺,雅施达,• Contraindication : pregnancy, stenosis of both renal artery
Cr > 3mg/dl, hyperkalimia
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Anti-hypertensive agents
angiotension II receptor blocker, ARB
Similar indication and contraindication with ACEI ,
Classification :
科素亚( losartan)
代文 (valsartan)
安博维 (irbesartan)
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Anti-hypertensive agents a - blocker• Indication :
Rapid effect, all type hypertension ,prostate proliferation
• Classification :
non-selective :酚妥拉明 Selective : 哌唑嗪
• Contraindication :
positional hypotension
drug resistance
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Principal to pick up hypertensive agents
Heart failure ACEI, diuretics , CCB ?Systolic hypertension diuretics , CCB ( 双氢吡啶类,长效)Diabetes, proteinuria ACEI, CCBRenal insufficiency(mild) ACEI(非肾血管性)Myocardial infarction ß- blocker (无内在拟交感) , ACEIStable angina ß-blocker , CCBDisorder of lipid a 1 blocker , ACEI, CCBpregnancy methyldopa , a 1 blockerProstate proliferation a 1 blocker
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Not recommended
1 asthma , depressive patient ß- blocker
2 gout diuretics
3 conduction block ß- blocker, CCB (非二氢吡啶类)4 renal vessel disease ACEI, ARB
5 peripheral vessel disease ß-blocker
6 liver disease 甲基多巴, 柳安苄心定7 lipid disorder ß- blocker , diuretics ( high dose )
8 pregnancy ACEI, ARB , diuretics
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Recommended protocol to treat hypertension
• Diuretics + ß-blocker
• Calcium channel blocker + ACE inhibitor
• Diuretics + ACE inhibitor ( or ARB)
• Calcium channel blocker + ß-blocker
• a - blocker + ß-blocker
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长期治疗随访实施过程治疗3个月后达到降压目标值 治疗3个月后未达到降压目标值 有明显副作用
• 继续治疗• 血压控制 一年以上 可减少剂量
• 增加剂量• 改用另一类 降压药• 联合用药
• 改用另一类 降压药• 减少剂量
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Clinical Type
Hypertensive crisis( 危象): BP increased rapidly in short time, DBP>120 or 130mmHg, combined with severe symptoms, maybe leading to death. Including : hypertensive urgencies (急症) w/o target damage hypertensive emergencies (危症) w/ target damage
hypertensive urgencies w/ grade3 eye ground is called 急进型 hypertension hypertensive urgencies w/ grade 4 eye ground is called 恶性 hypertension
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SBP 升高为主, DBP也可升高 血压突然急剧升高,周围血管阻力增加 出现头痛,呕吐,心悸,气急,视力模糊 靶器官病变,如心绞痛,肺水肿,高血压脑 病等。Hypertensive encephalopathy血压突然急剧升高致急性脑循 环障碍引起脑水肿和颅内压增高而产生的 临床症状。 包括严重头痛,呕吐,神志改变(烦躁, 意识模糊,抽搐,昏迷等)
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Malignant hypertension以肾小动脉坏死为突出特征•发病急骤,多见于中,青年•血压显著升高, DBP 》 130mmHg•头痛,视力模糊,眼底 III--IV 级改变•肾脏损害突出:持续性蛋白尿,血尿,肾衰•进展迅速,不及时治疗,预后不良, 多死于肾衰,脑卒中,心衰。
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Treatment of hypertensive crisis
•硝普钠 Sodium nitroprusside•硝酸甘油 Nitroglycerin•尼卡地平 Nicardipine•乌拉地尔 Urapidil
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Senile hypertension• >60岁• Mostly systolic Bp increase• 由中年高血压延续者,多为混合型高血压• 易出现靶器官并发症• 易出现血压波动和体位性低血压,尤其服降压药后
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Case1:
56岁,男性,会计师。以发作性头晕一年,头疼伴耳鸣一周为主诉入院。一年前每于工作紧张或劳累时感觉头晕,经检查发现血压 155-160/95-98mmHg ,曾间断服用复方降压片。近一周来时有头痛、耳鸣,且睡眠不佳,血压 170/100mmHg ,为明确诊断来诊。病来饮食与二便均正常。既往无心肾疾病、脑血管病和糖尿病病史。吸烟 28 年,每天 10-30支。母亲患高血压病,病故于脑溢血。
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Physical examination
Bp168/97mmHg , P97次 / 分,体重 68Kg ,睑结膜无苍白,口唇无发绀,颈软,未闻及颈部血管杂音,双肺呼吸音清,心尖搏动位于胸骨左缘第 5肋间锁中线内 0.5cm处,范围 2.5cm ,心前区未触及震颤,叩诊心界不大,心率 97次 / 分,心律规整,主动脉瓣区可闻及较柔和的 2 级收缩期杂音,伴第 2 心音亢进。腹软,肝脾肋下未触及,未闻及腹部血管杂音。颈动脉、桡动脉和足背动脉搏动良好。
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Lab
尿常规未见异常, Glu 5.6mmol/L 、K+ 4.8mmol/L 、 Cr 76.6μmol/L , BUN 5.9mmol/L,cholesterol6.5mmol/L,TG 0.9mmol/L;胸片 : 双肺纹理增强 , 主动脉弓蛋壳样钙化 , 心胸比值 0.5 ;ECG : SR , HR95次 / 分,电轴 -35° , TI 、 AVL 、 V5-6 低平。
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Discussion.根据上述情况,该患的诊断是什么?为什么?.为了解该患可能存在的心血管病危险因素, 还应补充哪些检查?.为明确高血压的分期,还应做什么检查?.根据该患的高血压类别,应选用哪些治疗方法?.该患有无进行 ABPM 的必要性?.如果需要药物治疗,可选用哪些药物?.病史中疗效不佳的原因是什么?即使血压下 降到正常范围,是否达到治疗目的?