河南省人民医院高血压科赵海鹰文档资料.ppt
特 点,一 涉及面广二 定义及诊治程序不规范三 参考资料少四 预后差,七个流程,理清思路,第一步（Step one）定义是否准确,第二步（Step Two）排除假性难治性高血压,排除假性难治性高血压Exclude Pseudoresistance,依从性：40%中断治疗（新诊断的第1年）40%继续治疗（以后5-10年）16%白大衣效应：在难治性高血压中更常见约20%-30%,血压测量不准确,第三步（Step Three）鉴别和逆转生活方式,Franminghanm研究60-70%的高血压病人有肥胖，并随年龄增加。在高血压肥胖病人中75%不限盐饮食，当体重减轻10kg血压达正常。肥胖高血压病人减肥比限盐更重要,肥胖,obesity is a common feature of patients with resistant hypertension.Mechanisms of obesity-induced hypertension are complex and not fullyelucidated but include impaired sodium excretion,increased sympathetic nervous system activity,and activation of the renin-angiotensin-aldosterone system.,体力活动与血压,1983年美国哈佛大学男性校友随访6-8年的结果表明，体力活动指数及是否参加剧烈运动项目（跑步、游泳、手球、网球、平地滑雪等）与高血压发病率呈副相关。每周参加运动项目的时数越多，发生高血压的危险就越低。,Dietary Approaches Stop Hypertension饮食控制终止高血压,U.S.DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Heart,Lung,and Blood Institute,NIH Publication No.06-4082Originally Printed 1998Revised April 2006,高盐高胆固醇高脂肪低钾低钙低镁低膳食纤维低优质蛋白,高血压,第四步（Step Four）终止或最小化升高血压的药物,甘草长期服用可引起血压升高机制明确,第五步 Step Five（筛查继发性高血压）,OSAS与高血压关系,国外流行病学研究表明，OSAS与高血压具有很强的相关性至少30%的高血压患者合并OSAS50%以上的OSAS患者有高血压OSAS是独立于年龄、体重、饮食、遗传等原因的高血压发病因素之一，是高血压发展的重要危险因素。,原醛的筛查,一 筛查的必要性二 疑惑三 筛查步骤,原醛患病率高,原醛筛查必要性,患病率高 临床症状不典型预后差（but also because PA patients have higher cardiovascular morbidity and mortality than age-and sex-matched patients with essential hypertension and the same degree of blood pressure elevation）可治疗性或可治愈性疾病,原醛的疑惑,一 血压并不顽固二 血钾不低三 肾素不低四 醛固酮不高 五 影像学与临床不符 六 手术后血压仍然高,How frequent is hypokalemia in PA?In recent studies,only a minority of patients with PA(937%)had hypokalemia.Thus,normokalemic hypertension constitutes the most common presentation of the disease,with hypokalemia probably present in only the more severe cases.Half the patients with an APA and 17%of those with idiopathic hyperaldosteronism(IHA)had serum potassium concentrations less than 3.5 mmol/liter.Thus,the presence of hypokalemia has low sensitivity and specificity and a low positive predictive value for the diagnosis of PA.,Case Detection,Diagnosis,and Treatment of Patients with Primary Aldosteronism:An Endocrine Society Clinical Practice Guideline,醛固酮可以不升高,Of 555 patientsdiagnosed with PAL at GHHU between 1993 and 1999,414(75%)had upright plasma aldosterone levels 30 ng/100 mLand 143(26%)had levels 15 ng/100 mL.,The Endocrinologist 2004;14:267276The AldosteroneRenin Ratio in Screening for Primary Aldosteronism Michael Stowasser,FRACP,PhD*and Richard D.Gordon,FRACP,PhD,MD,影响肾素因素较多,低盐饮食降压药物的影响血钾水平钠的摄入量年龄肾功能情况肾血管性高血压,ARR比值,是筛查原发性醛固酮增多症的第一步（严格控制药物及其他条件）欧洲高血压指南2003版ARR50建议继续筛查(肾素单位：ng/ml小时,ALD pg/ml）,肾上腺囊肿,在筛查继发性高血压中肾上腺功能比形态更重要,原发性醛固酮增多症,04年CT,2011年CT,手术效果差与术前未确定性质直接相关,肾动脉狭窄,在高血压科住院患者中继发性高血压病因第一位老年患者动脉粥样硬化为主青年病因大动脉炎为主儿童病因大动脉炎为主,肾动脉狭窄临床诊断方法,超声检查,漏诊率高,磁共振,假阳性率高,放射性核素,假阳性率高、且不能清楚的显示狭窄的部位和程度,DSA,可清楚的显示狭窄的程度和部位，但费用高不能普及,血管三维成像技术,阳性率高，与DSA符合率98%以上（分支和肾内狭窄显示不清），费用适中。,The best screening test for pheochromocytoma is plasma free metanephrines(normetanephrine and metanephrine),which carries a 99%sensitivity and an 89%specificity.,Lenders JW,Eisenhofer G,Mannelli M,Pacak K.Phaeochromocytoma.Lancet.2005;366:665 675,嗜铬细胞瘤,Right cerebellar cerebral hemorrhage,plasma MN:39.76(090 pg/ml）plasma NMN:4415.84(0200 pg/ml),neck paraganglioma,骶骨嗜铬细胞瘤,神经精神因素,焦虑与抑郁可导致血压不易控制发作性高血压已经引起高血压学界的关注,血压发作性升高,一 首先排除嗜铬细胞瘤（2%，虽然占发作性 比例并不高）二 敏感性和特异性均高的方法是血浆FMN、FNMN测定三 一定做ABPM四 应建立发作性高血压概念五 应重视这一特殊类型高血压六 发病机制需要探讨,继发性检查,肾上腺、肾动脉、肾脏薄层CT扫描,血浆游离3甲氧基肾上腺素及3甲氧基去甲肾上腺素测定,血浆肾素活性、醛固酮浓度测定,血电解质（血钾、钠、氯、钙）,血常规、尿常规,各种激素的检测,第六步（Step Six）药物疗法,利尿剂的使用,investigators at Mayo Clinic found that patients referred for resistant hypertension often had occult volume expansion underlying their treatment resistance,Resistant hypertension:comparing hemodynamic management to specialist care.Hypertension.2002;39:982988.,增加利尿剂的剂量或据肾功能改变利尿剂的类型In patients with underlying CKD(creatinine clearance 30 mL/min),loop diuretics may be necessary for effective volume and blood pressure control.,两种药物的联合,The combinations that included a thiazide diuretic were consistently more effective than combinations that did not include the diuretic.,Results of combination anti-hypertensive Therapy after failure of each of the components J Hum Hypertens.1995;9:791796.,三种药物的联合,must be tailored on an individual basis taking into consideration prior benefit,history of adverse events,contributing factors,including concomitant disease processes such as CKD or diabetes,patient financial limitations.,三种药物的联合,a triple drug regimen of an ACE inhibitor or ARB,calcium channel blocker,and a thiazide diuretic is effective and generally well tolerated.,第七步（Step Seven）,有回顾性研究资料显示：顽固性高血压转至高血压专科随访一年血压下降18/9mmHg,血压控制率由18%提高至52%,Mansoor GA.Blood pressure controlin the hypertension clinic.Am J Hypertens.2003;16:878880.,In a separate retrospective analysis,hypertension specialists at the Rush University Hypertension Center wereable to control blood pressure to 140/90 mm Hg in 53%of patients referred for resistant hypertension,谢 谢,
